Primary Care Coding Alert

Question: A family practitioner (FP) and resident go to see a patient in a nursing home during rounds, but only the resident sees the patient face-to-face. The FP and resident, however, do discuss the patient. How is this coded?

Anonymous Florida Subscriber

Answer: The Health Care Financing Administration (HCFA) has released instructions for teaching physician services which apply to residents providing services. The guidelines were in developed in 1996 to reduce confusion related to resident teaching programs. Under Medicare, Part A, residents are paid by the teaching hospital.

Teaching physicians may charge for their services but only if they are physically present when caring for the patient, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in
North Augusta, S.C.

HCFA says, Payment may be made for physician services furnished in teaching settings under the physician fee schedule only if the services are personally furnished by a physician who is not a resident or the services are furnished jointly by a teaching physician and resident or by a resident in the presence of a teaching physician with certain exceptions: If a resident participates in a service furnished in a teaching setting, payment may be made for the services 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.

For a teaching physician to be paid for an appropriate level of E/M service99212-99215 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: ranging from a problem-focused to a comprehensive history, a problem-focused to a comprehensive examination and a straightforward medical decision to one that is of high complexity) or 99201-99205 for new patientsthe FP must document his or her participation in the key components.

There are some exceptions, however, which Callaway-Stradley says were put in place to teach residents how to develop personal relationships with their patients in the primary-care setting. To help promote that skill, the physician remains outside the patients room but is available for consultation. In this case, teaching physicians will be paid for the appropriate E/M codes for services furnished by the resident, and the physician need not be present. All of the following conditions must be met:

1. The services must be furnished in a center located in the outpatient department of a hospital or other ambulatory care entity in which the time spent by residents in patient care activities is included in determining direct GME (graduate medical education) payments to a teaching hospital by the hospitals fiscal intermediary. In the case of a non-hospital entity, [...]