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, the carrier verifies with the fiscal intermediary that the entity meets the requirements of a written agreement between the hospital and entity.

2. Any resident furnishing the service without the presence of a teaching physician must have completed more than six months of an approved residency program.

3. The teaching physician in whose name the payment is sought must not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability.

4. The patients must be an identifiable group of individuals who consider the center to be the continuing source of their health care in which services are furnished by residents under the medical direction of teaching physicians. The residents must generally follow the same group of patients throughout the course of their residency program.

5. The range of services furnished by the residents includes acute care, chronic care, comprehensive care and coordination of care furnished by other providers.

Tom Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md., reminds FPs that to get paid, they must be present, as well as make an addendum to the residents documentation stating that the FP was in attendance with the patient and resident, overseeing the history, examination and medical decision-making. Be sure to indicate that you reviewed and discussed with the resident the three components of the visit and describe in a sentence what you have found for the history, exam and assessment.

Andrea Lamb, CPC, billing clerk, Upshor Medical Management Services, a managed medical practice in Buckhannon, W.Va., says that if the teaching hospital has established an agreement with the nursing home, FPs may get paid for their services if they initiated the careadmitted the patient into the nursing homeeven if the resident takes over the examination. The above-mentioned conditions for the residency program, however, must be met.