Teaching Physician Payment
Regulations Under the Medicare Part B Program; Billing for
the Services of Resident and Fellows in Their Own Name
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Related Resources
AAMC Documents
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Background
The final rule for teaching physicians has been in effect since
July 1, 1996. Periodic clarifications of the rule have been issued
by HCFA in addition to the final Carrier Manual Instructions.
The Medicare program's final rule for teaching physicians replaced
Intermediary Letter 372 Guidelines (IL-372) that were in effect
for nearly 30 years. IL-372 specified the requirements for billing
by teaching physicians when these services involved residents. The
criteria for billing expressed in IL-372 were ambiguous and not
well communicated by the Health Care Financing Administration (HCFA)
and its local carriers relative to the requirements for the physical
presence of the supervising teaching physician for visit and consultation
services. However, the guidelines did specify the need for the presence
of the teaching physician during major and complex surgical procedures.
The AAMC considers the 1996 final rule to be new policy with a new
set of requirements that are substantially different from the payment
policy for teaching physicians expressed in IL-372 Guidelines. (A
complete summary of the final rule is contained in a presidential
memo #95-68, issued December 16, 1995 and additional clarifications
issued on October 25, 1996, February 3, 1997, and February 9, 1998.)
The general rule, effective July 1, 1996, is as follows:
If a resident (or fellow) participates in a service furnished
in a teaching setting, a Part B payment will be allowed only if
the teaching physician is present to perform or observe the resident
perform, the "key" portion of any service or procedure
for which payment is sought. Each individual physician may determine
the "key" portion of any service or procedure furnished.
The "key" portion for a visit or consultation service
is defined in CPT as including the activities of history, physical
exam and medical decision-making. The "key" portion for
a surgical or diagnostic procedure is self-defined by the physician.
The rule provides for an exception to the general physical presence
requirement for low level visit services provided in certain primary
care outpatient centers by residents being trained in the specialties
of general internal medicine, family practice, gerontology, OBGYN
and pediatrics.
Documentation Requirements
The teaching physician has special documentation instructions under
the final rule. The teaching physician may substantiate any service
billed to the Medicare program by writing or dictating a summary
note of the services performed personally or directly observed.
The teaching physician's note may be a summary note that confirms
or revises the history of present illness, the exam, and the medical
decision making activities, combined with the more detailed note
of the resident. (See AAMC templates on how to structure an appropriate
note for EM services.) For other services, such as a single surgical
procedure and diagnostic tests, a simple attestation of physical
presence of the teaching physician during the key portion of the
procedure or test is all that is required. For overlapping, concurrent
surgical procedures performed or observed by the teaching physician,
however, he/she must provide a patient-specific personal note of
the procedures billed.
Billing for the Services of Residents and Clinical Fellows "In
Their Own Name"
The rule also addresses the circumstances for when it is appropriate
to bill for the services of residents and clinical fellows "in
their own name". A resident or fellow may bill for services
they perform in their own name in only two situations: 1) when under
in a moonlighting situation; and 2) if providing service in an unapproved
training program, that is a program not approved by the ACGME or
the ABMS.
(For complete details on these issues, link to the final Carrier
Manual Instructions, issued May 1997 and the AAMC Memo #96-12 on
the Billing for the Services of Clinical Fellows, issued March 10,
1996. For the complete text of the HCFA final rule for teaching
physicians, see the Federal Register, volume 60, December 8, 1995
in text format and PDF format).
Administration Action
Various clarifications have been issued by HCFA since the final
rule was published.
AAMC Action
AAMC staff have worked continuously to clarify the provisions of
the final rule. These have been communicated to the membership via
the internet and presidential memos.
Contacts
Ivy Baer, J.D.
Director and Regulatory Counsel
Health Care Affairs
ibaer@aamc.org
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