More than one large institution has run afoul of the rules related to reporting services provided jointly by a resident and an attending, and returned significant funds to Medicare and paid substantial fines. And yet, the rules are not that complicated and have not changed recently. This is the key point: the attending or teaching physician can bill for Evaluation and Management (E/M) services provided jointly with a resident in an approved Graduate Medical Education setting under his/her own provider number only if the teaching physician sees and examines the patient, participates in the treatment and writes a note documenting this service and tying it to the resident’s note. Three things: sees and examines the patient, participates in the treatment and writes a note. If the attending is physically present while the resident is performing the history and exam, that meets the criteria for seen and examined.
Let’s look at this one by one. For an E/M service (admission, office visit, subsequent hospital visit) the attending must perform or be present during the key and critical components of the service. That is, see and examine the patient. The attending must participate in the care of the patient and personally document participation. The Medicare Claims Processing Manual states, “Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.” That is, if the attending does not personally write a note, the service may not be billed. The attending might see the patient before or after the resident, or in unusual circumstances, at the same time as the resident. In all cases, the attending must participate in the decision making and treatment plans of the patient. The attending must personally document the note. Countersignature, or the simple statement, “Seen and agree” are both insufficient.
Supervision, case conferences, discussions alone: these do not allow the attending to report (that is bill for) a service that a resident provides.
The Medicare Claims Processing Manual gives examples of acceptable documentation, which I have reproduced below. Frankly, I suggest adding clinical detail to that patient’s care that day, to avoid the appearance of identical attestation statements.
Examples from the Medicare Claims Processing Manual
Admitting Note: “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
Follow-up Visit: “Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
Follow-up Visit: “Hospital Day #5. I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”
Initial or Follow-up Visit: “I was present with the resident during the history and exam.
I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
Follow-up Visit: “I saw the patient with the resident and agree with the resident’s findings and plan.”
Initial Visit: “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
Initial or Follow-up Visit: “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
Follow-up Visit: “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
Follow-up Visit: “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”
There is a primary care exception available for some primary care residency programs. There are different rules for psychiatry, for time based codes and for minor surgical procedures, endoscopies and major surgery. But they all follow the basic mandate that the attending, under whose provider number the claim is reported and paid, provide part of the service and document the participation. Supervision alone is insufficient.