ED Coding and Reimbursement Alert

In teaching hospitals (hospitals with graduate medical residency programs), emergency department (ED) physicians often supervise medical residents, providing guidance adnd oversight as the physicians-in-training treat patients.

Because the teaching physician physically may not perform all of the services provided during the patient visit but is legally responsible for the care provided by the residents he or she supervises, the Health Care Financing Administration (HCFA) has special rules governing how teaching physicians and residents report procedures and services.

Physician Must Be Present During
Key Portion of Service

HCFAs carrier instructions concerning how to reimburse teaching physician and resident medical services state that if a resident participates in a service furnished in a teaching setting, pay for the service of a teaching physician under the physician fee schedule only if the teaching physician is present during the key portion of the service for which payment is sought.

The instructions do not state, however, what a key portion is. It is difficult to understand from a laypersons perspective, it is more of a clinical determination, explains John Donnan, MBA, administrative manager for the emergency department at Massachusetts General Hospital, Boston, MA. For example, in a lumbar puncture, if the resident performs the procedure, the teaching physician must be present to oversee the placement of the needle in the space and to see that spinal fluid and not blood is drawn. And if a long-bone fracture is set, the physician must be there to determine that the bone is set and that the splint or cast does not compromise neuromuscular function. Basically, the physician must be there during the portion of the visit in which the main treatment is performed. The ED physician cannot just stick his or her head in the door and then bill for the visit.

The documentation by the teaching physician and resident must indicate his or her presence during the performance of the procedure.

For evaluation and management (E/M) services, the key portions are: a relevant history of present illness and prior diagnostic tests; the major findings of the physical examination; the assessment, clinical impression or diagnosis; and the plan of care, advises Todd Thomas, CPC, CCS-P, president of Oklahoma City, OK-based Thomas and Associates, a consulting firm specializing in emergency medicine practice management and reimbursement.

If the teaching physician is present during the patient encounter and all of the required elements are obtained and documented by the resident, the resident should include in the documentation the teaching physicians presence and participation in the key components of the visit, says Thomas. The teaching physicians actual documentation may be minimal, but it must include confirmation of the performance of the key components [listed above] and the teaching physicians presence during that portion.

For example, continues Donnan, a resident may take the history and perform the initial examination of the patient and, perhaps, establish a diagnosis. Then the teaching physician will come in, review the residents documentation, repeat key elements of the examination pertinent to the patients condition, establish the definitive diagnosis and plan of treatment.

Tie In Between Resident and
Physician Documentation

A key requirement in these types of services is the tethering statement or statement that ties in the teaching physician documentation to the residents documentation. Taken together, both sets of documentation of the patient encounter are used to determine the level of service reported (99281-99285, emergency evaluation and management services).

If the resident performs the history and physical exam, the ED physician must repeat the key elements of the exam and tie his or her note into the note of the exam performed by the resident, citing the relevant history obtained from the interview with the patient, adds Thomas. The physician does not need to restate the review of systems and past, family, social history.

Again, he says, the statement by the teaching physician may be limited but must include a confirmation of the residents documentation by the teaching physicians commentswhich either revise or confirm the findings of the residents physical exam with the teaching physicians own examand a discussion of the history and medical decision-making.

It is the combined entries that must be adequate to substantiate the level of service required by the patient, and the level of service billed, Thomas says.

Primary Care Exception Is
Not Applicable to Main ED

HCFAs rule contains an exception to the requirement that the teaching physician be present for the key portions of service in designated primary care centers. These centers must be located in an outpatient department of a hospital or other ambulatory care facility.

For certain low-level E/M services performed in centers that meet the rules requirements, the teaching physician does not have to be present for the key portions of the service, provided the resident has been in an approved residency program for more than six months.

This exception, however, applies only to services that can be reported with codes 99201-99203 (office/outpatient evaluation and management services, new patient) and 99211-99213 (office/outpatient evaluation and management services, established patient). Because there is no established patient distinction in the regular ED, these codes are not used and the exception does not apply to services in the main ED, note Thomas and Donnan.

However, certain urgent care centers located within the ED might be eligible to use the exception.

Coders tip: Another confusing area for teaching physicians in the ED is the performance of critical care E/M services. Emergency physicians should note that when a resident and a physician perform critical care services together, only the time that the teaching physician is present can be counted toward the total critical care time.