Billing and Documentation Guidelines for Teaching Physicians, Interns, and Residents

 

Teaching Physicians, Interns, and Residents Guidelines Updates July 2022

 

This article will address the changes that CMS addressed recently for Teaching Physicians, Interns, and Residents in various settings and services provided in those settings.

Medicare will pay for services in a teaching setting based on the Medicare Physician Fee Schedule (PFS) when services are provided by a physician not a resident or when a resident provides a service and the teaching physician is present (physically or via audio/video real-time technology in a residency training site outside a Metropolitan Statistical Area (MSA).

When interpreting diagnostic radiology and other diagnostic tests in a Teaching Setting, CMS will pay for the interpretation of diagnostic radiology or other diagnostic tests under the PFS when completed by a physician. CMS will also pay the PFS rate in a residency training site when that site is outside an MSA, to a resident who interprets a diagnostic radiology and other diagnostic tests when the teaching physician is present through audio/video real-time technology. The documentation in the patient’s medical record must show that the physician took part in the interpretation of the diagnostic tests.

For psychiatric services, CMS will pay the PFS rate under an approved GME Program, with the appropriate documentation in the patient’s medical record detailing the physician’s presence through a 1-way mirror, video equipment, or similar devices.

Teaching Physician Billing Requirements are still the same except when total time decides the office or outpatient E/M visit level, when billing the only time that should be recorded is that of the teaching physician. When selecting a visit level, only count the time that the teaching physician spent doing the components of the CPT code that they are choosing for billing purposes. During a PHE, the teaching physician’s time can be included when they are present audio/video real-time technology.

The guidelines for documentation in the medical record now include the need for the teaching physician to document their physical or virtual presence in the visit, only if the residency training site is outside the MSA,  and the documentation must note the services rendered during the physician’s presence through audio/video real-time technology.

Starting January 1, 2022, when you select time-based office and or outpatient E/M visit levels, the physician may include only the time spent doing qualifying activities, including your presence with the
residents doing those activities.

Under the primary care exception, you can’t use time to select visit level. The physician may only use Medical Decision Making (MDM) to select the E/M visit level. During COVID-19 PHE was expanded and this impacted the residents’ services list. After PHE is over, the physician can’t include visit level 4 or visit level 5 in the office setting or outpatient E/M visits in the primary care exception.

These changes that are going into effect will require a complete review by the physician and their staff members to ensure that all requirements for physician presence in a visit, interpretation, billing, and especially documentation in the patient’s medical record. When in doubt, reviewing the CMS Manual and all MLN products to help to keep the practice or organization compliant to the recent changes and current billing practices.

 

More information regarding the Patient Rights under the No Surprises Act by the Centers for Medicare Medicaid Services (CMS) by Kevin Harrington

The people covered under insurance and those who are not covered by insurance now have protection from receiving a bill from a provider that they did not have any idea of how much the bill would actually be from the provider.

This new act called the “No Surprises Act” will be instrumental in reducing the occurrences of surprise medical bills by providers moving forward. According to the Human Services Secretary Xavier Becerra no patient or responsible party should worry about going bankrupt after an illness. There has been misconception by consumers that when they are in an employer-sponsored health plan that they would be insulated from high out-of-pocket expenses related to the healthcare they receive. This misconception can be expensive as some of the emergency services one receives ended up creating a considerable amount of out-of-pocket expenses for healthcare consumers. These surprise bills received from a provider could sometimes be as high as 7-10 times higher than those with coverage for the encounter in the Emergency Department.

Historically, there are varying degrees of protection among the states, and even though they are looking to protect the patient in some way, the states are experiencing many limitations in protecting the patients. The No Surprise Act that was brought forth by the Biden-Harris Administration have put forth efforts to stop providers from balance billing the patient for services rendered. Also, the Biden-Harris Administration recently added some features for resolving disputed claims so they will not end up with a huge surprise bill in the future.

According to CMS, this bill provides special protections from surprise medical billing that includes:

·        Establishing an independent dispute resolution process to determine out-of-network payment amounts between providers (including air ambulance providers) or facilities and health plans.

·        Requiring good-faith estimates of medical items or services for uninsured (or self-paying) individuals

·        Establishing a patient-provider dispute resolution process for uninsured (or self-paying) individuals to determine payment amounts due to a provider or facility under certain circumstances.

·        Providing a way to appeal certain health plan decisions.

For most of us, this will be a great savings for when we receive healthcare services in the future. More importantly, this will also help to reduce health insurance premiums for healthcare consumers.

For providers, they will need to be more adept in their billing processes, from registration to claims submission. It will require more transparency from the provider’s side of the equation, but should end up making the deliver of healthcare services more straightforward.

 

Reference

Centers for Medicare. (2021). Overview of rules & fact sheets. Retrieved from: https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets