Part B Insider (Multispecialty) Coding Alert

Anesthesiologists must be personally present to bill based on time

A new clarification from the Centers from Medicare & Medicaid Services makes it easier than ever to bill for teaching physicians' supervision of residents--but only if you follow the rules. 

In Transmittal 1780, dated November 2002, CMS clarified that a teaching physician didn't have to document the key portions of the patient's evaluation and management service (see PBI, Vol. 5, No. 7). Now CMS has further clarified the rules for teaching physicians' documentation in Transmittal 811, dated Jan. 13. CMS says:

• Physicians can use macros in electronic medical records to speed up the process of signing off on residents' documentation. Physicians had asked the Physician Regulatory Issues Team at CMS for clarification of this issue (see PBI, Vol. 6, No. 31). But the teaching physician and resident can't both use macros, and the teaching physician must add enough details to allow a medical necessity determination. The teaching physician must have a secure password for accessing the electronic health record.

• The physician must either perform the key portions of the E/M personally or be "physically present" while the resident performs them. The transmittal defines "physically present" as meaning the physician must be in the same room or the same partitioned/curtained area if the room has multiple patients. It's up to the teaching physician to define the "critical or key portions" of the E/M.

• Residents can assist with the Initial Preventive Physical Exam benefit (code G0344).

• If the resident performs endoscopic services, the teaching physician must be present from the insertion of the endoscope to the removal of the endoscope. The physician can't view from another room.

• The resident can review diagnostic tests if the teaching physician documents reviewing the images and the resident's interpretation. The teaching physician must either edit the resident's findings or indicate agreement with them.

• A teaching anesthesiologist can bill the usual base units and anesthesia time for supervising two residents simultaneously, using the AA modifier. But the teaching physician can only bill for the base units and anesthesia time for the amount of time he or she is personally present.

• It's not enough for the teaching physicians to simply write, "agree with the above," or "reviewed, rounded, agree," or similar terms in the documentation.

Avoid Cookie-Cutter Statements In Macros

Your electronic medical record's macro can include a simple statement such as, "'I have personally seen and evaluated the patient. I have reviewed the resident's note and agree with the assessment and plan,' followed by the teaching physician's clinical summary," according to David Weirick, internal coding auditor with the Kalamazoo Center for Medical Studies at Michigan State University.

But you should make sure your macro includes some patient-specific information and isn't just a "cookie cutter" statement, says Mary Dressler, medical compliance specialist with the Office of Billing Compliance at the University of Oklahoma Health Sciences Center.

"Anyone using an electronic health record must have a unique, personal password to access the system and only people with the appropriate access are able to dictate, amend and sign notes," Weirick explains.

You can also set up your medical notes so that certain sections of the record require a password to change them, adds Suzan Hvizdash, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. This may require more programming and a learning curve for your doctors, but "in the end it is of great benefit to the physicians."

When a resident is involved in treating a patient, you must document the teaching physician's presence, says Jo Ann Kergides, a physician services coder with the School of Osteopathic Medicine at the University of Medicine & Dentistry of New Jersey in Stratford. "The only way teaching physicians can prove that they were present is through their documentation, by signing and dating the note," she adds.

Tip: "A lay person should be able to see the teaching physician was present by his/her documentation," says Dressler