Medicare Compliance & Reimbursement

Question: We are getting a lot of feedback that our emergency physician faculty members, who are supervising residents, can't report procedures that allow "supervision of key components." Rather, we are told that they must remain at the bedside the entire time in order to bill for the procedure. For many procedures, this isn't a problem, but watching a 1st year resident sew up a 15cm laceration for an hour isn't practical in a busy ED. Of course, the physicians are always within the department, but do they have to remain at the bedside for the entire procedure? Our charting system offers two check boxes: 1. "I was present for and supervised the entire procedure" and 2. "I was present for key components of the procedure." For number 2, we aren't billing. While we are on that topic, what exactly is "present"? Does it mean in the same room, in the department, or in the hospital?

Answer: You should question the source of that information. For Medicare patients, the answer to your questions can be found in Transmittal 1780 and Transmittal 811. These transmittals contain rules about the level of supervision required for various procedures performed in a teaching setting.

In general, Medicare will pay for physician E/M services furnished in a teaching setting under the Physician Fee Schedule only if the services are furnished by a resident seeing a patient in the "physical presence" of a teaching physician who documents his or her presence during the performance of the critical or key portions of the service and participation in the management of the patient.

Alternatively the teaching physician and the resident may be seeing the patient at different times during a visit, provided the teaching physician independently performs the critical or key portions of the service.

For procedures, a distinction is made by Medicare between minor procedures (those lasting less than 5 minutes) and major procedures which typically take longer than 5 minutes. Basically, the teaching physician must be physically present at the bedside for the entire time in order report a minor procedure, defined as one that takes three to five minutes to complete.

On the other hand, major procedures (defined as anything taking longer than five minutes) require only that the attending or teaching physician be present for the key aspects of the procedure and it is up to the attending to determine the key aspects of the service. Very few procedures involving a resident performed in an academic setting take less than five minutes to complete.

For those procedures where they are not physically present for the entire service, the teaching physician must be immediately available to assist as needed. Be sure the chart documentation supports the teaching physicians' actual involvement in the case and the other documentation requirements are met before reporting the service.