University of Iowa Roy J. and Lucille A. Carver College of Medicine

Mandatory Continuing Education for Faculty: Teaching Physician Billing Rules

You have accessed the Joint Office for Compliance Program’s mandatory continuing education program associated with the Teaching Physician Billing Rules. If you have accessed this education program in error, and would like to move to a different section of the Compliance Website, please click on one of the sections listed on the column to the left of this page.

I. Overview of Education Requirement

The Joint Office for Compliance Program (JOC) requires all teaching physicians who bill for services through the FPP to complete this education program annually.

To fulfill the education requirement you must satisfactorily complete an exam, which can be accessed at any time on-line by clicking the button on the left, titled " Take Exam." You must achieve a score of 11 (out of 15) or higher to successfully complete this mandatory education requirement. You can re-take the exam as many times as necessary to achieve a passing score. Upon completing the exam, you will be notified of your results and will be given an explanation for each incorrect answer. Your score will be forwarded to the Joint Office for Compliance. You will receive an email response acknowledging your completion of the exam. The Iowa City VAMC will be notified of the satisfactory completion of this education program for teaching physicians who also have clinical privileges at the VAMC.

If you have any questions, contact your department compliance liaison or one of the staff in the Joint Office for Compliance.

II. Introduction

The purpose of this educational material is to reinforce and to assess your knowledge of:

National attention to compliance issues
Joint Office for Compliance Program
Detailed Review of FPP Teaching Physician Billing Policy - the FPP’s policy regarding the submission of bills when teaching physicians (TP) and residents/fellows are involved with the provision of these services.
Services excluded from the FPP Teaching Physician Billing Policy

III. National Attention to Compliance

Prior to the implementation of Medicare and Medicaid programs, resident and fellow physicians provided the majority of clinical services in many traditional academic medical centers. The federal government provided payments to academic medical centers for a portion of the costs of running residency/fellowship programs. Teaching physicians provided clinical supervision, but many focused their attention on teaching and research.
Similar to the campaign against excessive costs in the defense industry in the 1970s and 1980s, the federal government began focusing on fraud and abuse associated with the healthcare industry in the mid-1990s. A major focus has been at academic medical centers. Since the federal government provides payments to academic medical centers for residency/fellowship training, they want to ensure that the teaching physician provides sufficient involvement to substantiate the "additional" payment associated with the services billed by the teaching physician.
The Federal Bureau of Investigation (FBI) has continued to increase their efforts in combating health care fraud and abuse.
In addition, the Federal Civil False Claims Act allows private citizens to file a lawsuit in the name of the U.S. Government charging fraud and abuse and then share in any money recovered (these are known as Qui Tam or "whistleblower" suits.)

IV. Joint Office for Compliance Program

University of Iowa Health Care has developed a Compliance Program to ensure that services billed are consistent with guidance from third party payors.
All employees who participate in billing physician services have had elements related to compliance included in their job descriptions. In addition, department faculty compensation plans include compliance as one element used in determining the clinical component of individual faculty salaries.
A Compliance Helpline has been implemented for any staff to anonymously report compliance concerns.
The FPP established a policy whereby medical record documentation must be reviewed for 100% of all inpatient services prior to billing to ensure the documentation supports the billed service.
Mandatory education programs have been established for all teaching physicians and all billing staff.
An internal audit program has been developed which audits a sample of each physician's billed services. The Joint Office for Compliance has established standards which expects physicians to reach 100% compliance with the teaching physician billing rules and 90% compliance with proper CPT code selection.
Providers who do not reach the standards may need to undergo additional education and re-audit. Depending on the circumstances, a fee may be assessed to the department for the cost of re-education and re-audit.

V. Teaching Physician Billing Policy

Overview
1. The FPP developed a unified policy (Teaching Physician Billing Policy) pertaining to the submission of bills to third party payors for services involving both teaching physicians and residents or fellows.
2. Fellows in Accreditation Council for Graduate Medical Education (ACGME) accredited programs are considered the same as residents for the purposes of the Teaching Physician Billing Policy. The same supervision and documentation requirements apply. The only exception is residents or fellows who are practicing under approved moonlighting arrangements (for example in the emergency room).
3. The policy is intended to comply with the Centers for Medicare and Medicaid’s Teaching Physician Billing Requirements.
4. The teaching physician must be physically present for the "key portion" of the service rendered by a resident/fellow in order to submit bills.
5. The documentation in the medical record must support the specific level of service billed and support the teaching physician's physical presence during the key portion. The documentation must be sufficient in detail to help the teaching physician recall the visit or service. If there is insufficient documentation, a bill should not be submitted.
6. Every entry in the medical record should clearly indicate who authored the entry.
Definition of Physical Presence and Documentation Requirements
1. Physical presence: The physical presence requirement describes when the TP must be present with the resident/fellow during the provision of care to substantiate the billed service. For some types of clinical services, the TP does not need to be present with the resident/fellow, but must see the patient him/herself to confirm/edit the resident's findings.
2. Documentation: The medical record must include documentation supporting the TP's compliance with the physical presence requirement and sufficient involvement to support the level of medical services provided. If the documentation requirements are met, the resident/fellow documentation may be combined with the TP documentation to support the service.
Specific Services: The Teaching Rules Billing Rules (TR) vary according to the types of physician services provided. Therefore, this education material is categorized first, by the type of clinical service, then by the teaching physician's (staff physician's) physical presence and documentation requirements.
1. Evaluation and Management Services- (Outpatient-clinic visits, hospital daily care, consultations, nursing home, home visits etc.)
  1. Physical presence
    1. The TP must clearly see the patient and participate personally in the patient's care consistent with the level of E&M service billed.
    2. Participation is defined as either personally performing the key portions of the service or observing the resident perform the key components.
    3. History, exam, and medical decision making are considered the key components.
    4. For initial hospital care, emergency department visits, new patient office visits, and inpatient and outpatient consultations, all three key components must be performed/observed by the TP.
    5. For office visits for established patients or subsequent hospital care visits, the TP needs to perform and document only 2 of the 3 key components, selecting which components based on the patient's condition.
    6. The requirements to bill a particular level of E&M service are described in CPT. The TP must perform enough personal work (either independently, or by the resident in the presence of the TP) to satisfy the requirements for the level of service billed.
  2. Documentation
    1. If all requirements are met, the combination of the resident's and TP's documentation for a service may be used to support the billed service.
    2. The TP must document that they performed the service or were physically present during the key or critical portions of the service when performed by the resident; and
    3. The participation of the teaching physician in the management of the patient.
    4. The combined entries of the resident and the TP must be adequate to substantiate the level of service required by the patient (i.e., the level of service must be medically necessary) and the service billed.
    5. TP must always document:
      - Statement establishing his/her presence (i.e., "my exam" or "reviewed with patient" or "patient seen and/or examined")
      - That he/she performed the critical or key portion(s) of the service or that he/she was present during the performance of the critical or key portion(s) and that he or she was directly involved in the management of the patient.
      - Refer to the resident's note for details of the visit service performed.
    - Examples of documentation expectations for three different scenarios are provided below:
      - All required elements are obtained personally by the TP without a resident or fellow present. If no resident has seen the patient, the TP should document on the same basis he/she would document an E/M service in a non-teaching setting.
      - All required elements are obtained by the resident in the presence or, jointly with, the TP and documented by the resident. The resident’s note may document the TP’s direct observation, performance and personal input into the key elements. The TP’s personal documentation must include a confirmation of the resident’s documentation and the TP’s presence during the service.
      - Selected required elements of the service for example history and exam are obtained by the resident independently. The TP repeats the key elements of the examination. These elements are discussed with the resident either prior to or after the TP’s personal service. The resident’s note may document the TP’s input into the history and medical decision making. The TP’s note must refer to the resident’s note/ findings and that he/she performed the critical or key portions of the service and that he/she was directly involved in the management of the patient.
2. Minor procedures: These clinical services consist of any procedure taking less than 5 minutes in duration.
  1. Physical presence The TP must be present during the entire procedure.
  2. Documentation The documentation may be provided by either the resident, the nurse, or personally by the TP. Avoid using the word "supervised" or phrase "directly supervised" or "personally supervised" as these statements do not necessarily convey that the TP was present for the entire minor procedure as is required. The documentation must state that the teaching physician was present during the entire procedure.
3. Major Procedures (surgical, high risk, and complex procedures): Includes any procedure taking greater than 5 minutes in duration. It includes procedures provided in clinics, at the bedside, and major procedures provided in ambulatory surgical suites and operative suites.
  1. Physical presence
    1. The teaching physician must be present during all key (critical) portions of the procedure. The teaching physician must be immediately available during all non-key portions of a surgical procedure.
    2. CMS has not defined the key portion of procedures. The teaching physician is allowed to define the key portion of each procedure.
    3. The teaching physician should not be involved in more that two overlapping procedures.
    4. The key portion of the procedures cannot overlap.
    5. If the teaching physician leaves the procedure before or after the key portions of the procedure to become involved in another procedure, he/she must arrange for another TP to be immediately available to intervene in the original procedure.
  2. Documentation
    1. If the TP was present for the entire procedure, the documentation can be made by either the TP, resident or other staff such as a nurse. It should state the TP was present for the entire procedure.
    2. If not present for the entire procedure, the documentation should indicate the TP was present for the key portion of the procedure, immediately available for the remainder of the procedure and define what the teaching physician views as the key portion of the procedure.
    3. For single surgical episodes (non-overlapping) the TP, resident, or other staff can document compliance.
    4. In the case of overlapping procedures, the TP must document compliance in his/her own note. The TP must document the key portion of each of the overlapping procedures using patient specific terms.
    5. If the TP was not immediately available for the non-key portions of the procedures supporting documentation should clearly identify which TP was immediately available.
4. Interventional Procedures: High risk procedures for which CMS policy or CPT descriptions indicate that the procedure requires personal supervision of its performance by a physician. Includes, but is not limited to: Interventional Radiology and Cardiology, Cardiac Catheterization, Cardiovascular Stress Tests, Transesophageal Echocardiography, Arthrograms, Myelograms, and EP Studies.
  1. Physical presence
    1. The TP must be present with the patient during all critical and key portions and remain immediately available to furnish services for the duration of the entire procedure.
    2. Key portions of two procedures being performed may not overlap.
    3. Observation via a monitor from another location is NOT acceptable to satisfy the physical presence requirement.
    4. Immediately available means that the TP must be in the area and not engaged in the key portion of an overlapping/concurrent procedure.
    5. When the CPT code description states "supervision and interpretation" (S&I), the TP must be present with the patient for the entire radiologic portion of the interventional procedure. These codes pay for both the performance and the interpretation of the findings.
    6. The same rules for surgical procedures, single and overlapping, apply to interventional procedures.
  2. Documentation
    1. If the TP is performing both the surgical and radiologic portions of the procedure, the documentation must indicate that the TP was present during the key/critical portions of the procedure.
    2. If the TP is billing an S&I code, the documentation must indicate that the TP was present during the surgical and radiologic portions of the procedure before moving on to another procedure.
    3. When performing an interventional procedure which may include multiple surgical and supervision and interpretation codes, there is no requirement that the TP document the key portions (of each code) if the TP is present for the entire procedure.
    4. For single cases (non-overlapping), the TP presence may be recorded by the resident or a nurse.
    5. If the TP leaves one procedure to begin an overlapping procedure, the TP must provide personal documentation. Documentation must include that the TP was present for the key portion, a definition of the key portion, and that the TP or back up TP was immediately available for the non-key portions.
    6. The TP must arrange for coverage for case one, if the TP becomes involved in an overlapping procedure.
    7. The interpretation report may be dictated by either the TP or the resident.
    8. If the resident prepares and signs the report, the TP must indicate in an attestation to the report that he/she has personally reviewed the film or tracing and the resident’s interpretation and either agrees/edits the findings.
    9. If the TP’s signature is the ONLY signature on the report, Medicare will assume the TP personally performed the interpretation. No other attestation is required.
5. Endoscopies
  1. Physical presence
    1. The TP must be present during the entire viewing portion of the procedure.
    2. The viewing portion is defined as insertion, viewing and withdrawal of the scope.
    3. Viewing via a monitor from a remote location or at a later time is not acceptable.
  2. Documentation
    1. The documentation should explicitly state the TP's presence.
    2. The TP may document his/her presence personally.
    3. The documentation may be made by residents, nurses, or an attestation statement and must be countersigned by the TP.
6. Radiology, Pathology and other non-interventional Diagnostic Tests
  1. Physical presence
    1. The TP must view the film/study.
    2. The TP must either personally perform and document the interpretation OR personally review the resident’s/fellow’s interpretation.
  2. Documentation
    1. There must be documentation the TP personally performed the interpretation or reviewed the film/study and resident/fellow interpetation.
    2. If a resident/fellow prepares and signs the interpretation, the TP must indicate he/she has reviewed the film/study and agrees /edits the findings.
    3. A countersignature of the resident’s interpretation by the TP is insufficient.
7. Psychiatry
  1. Physical presence
    1. For time based counseling codes; the physical presence requirement can be met by remote, simultaneous observation and immediate consultation with the resident/fellow.
    2. Audiovisual-only equipment (taped recording) does not meet this exception to the physical presence requirement. The teaching physician should only bill the time he/she spent observing the session.
    3. Evaluation and Management (E/M) services provided in Psychiatry need to comply with the same physical presence requirements of the other E/M services.
  2. Documentation
    1. The TP must document his/her own time spent and a description of the involvement in observing the service.
    2. He/She should only bill for the time spent directly observing the service.
    3. E/M services must comply with E/M documentation requirements.
8. Other Time Based Codes: Critical Care Services, Evaluation and Management: Counseling and/or Coordination of Care, Prolonged Services (Excluding Psychiatric counseling codes and anesthesia administration)
  1. Physical presence
    1. The TP must be present for the period of time for which the claim is made.
    2. Time for resident services in the absence of the TP can not be billed.
    3. Any time associated with a separate billable procedure must not be included in the total time of critical care billed.
  2. Documentation
    1. The TP must indicate the length of time he/she was directly involved with the service and a brief description of the service provided.
    2. The TP must document his/her presence and participation during the portions of the service that determines the level of service billed. The documentation of the TP may be brief, summary comments that tie into the resident’s/ fellow’s entry and confirm/ revise the key elements.
    3. Any time associated with a separate billable procedure must not be included in the total time of critical care billed.
9. Anesthesia: Medicare pays for anesthesiology services that are either personally performed (no reduction in payment) or medically directed (reduction in payments). The requirements for medically directed anesthesia services, whereby an anesthesiologist directs one, two, three or four concurrent anesthesia services provided by a team of qualified individuals (CRNAs, AA’s and/or residents) are different than the TP billing requirements.) The TP billing requirements address those services whereby one anesthesiologist supervises one resident/fellow and bills the service for an unreduced payment.
  1. Physical presence
    1. Anesthesia services are defined as: pre-anesthesia examination and evaluation, anesthesia plan and informed consent, intra-operative service, and post-anesthesia care.
    2. The TP must be present during the key portion of the procedure, including induction, emergence, and any other critical parts of the procedure and must be immediately available during the entire procedure to submit a bill.
    3. The TP is NOT required during the pre-op or post-op visits.
    4. If the TP is involved in concurrent procedures with more than one resident or with a resident and a non-physician anesthetist, bills should be submitted under the medical direction billing protocol.
  2. Documentation TP must indicate presence or participation during the key portion of the administration of the anesthesia.
    1. The TP must personally document his/her presence with the patient during the key portions of the procedure, including induction and emergence, or regional anesthesia and any other key portion of the procedure.
    2. The TP must document his/her immediate availability during the entire procedure.
    3. When a medical student or other student is involved, the TP must also document the pre-op and post-op visits.
10. Primary Care Exception: Select Evaluation & Management Services furnished in certain Primary Care Centers (Approved Primary Care Exception clinics: FCC & General OB/GYN) The Primary Care Exception may only be used for select CPT Codes: office visit codes (99201,99202,99203,99211,99212,99213)
  1. Physical Presence
    1. The TP is not required to see the patient. Claims may be submitted for services furnished by residents without the presence of a TP.
    2. The TP must review with each resident, during or immediately after each visit, the patient’s medical history, physical exam, diagnosis, and record of tests and therapies.
    3. The TP in whose name the payment is sought must not supervise more than four residents and must be immediately available when providing this supervision.
    4. The TP must not have any other responsibilities during the time the residents are seeing patients under the PC Exception (i.e., seeing patients independent of the resident.)
    5. The TP must assume all responsibility for the management of those patients.
    6. If a patient comes to the center and requires a more comprehensive visit service (level 4 or 5) that is unexpected and unscheduled by the center, the TP may see the patient, but must revert to the physical presence rule. The TP may continue to bill for other level 1, 2, and 3, E/M services furnished by up to 4 residents under his/her direct supervision under the exception during the same clinic session.
  2. Documentation
    1. The TP must document the extent of his/her own participation in the review and direction of the services furnished to each patient.
    2. Other documentation such as resident and clinic schedules should support that the TP is not supervising more than 4 residents at a time.

VI. Exclusions

The Teaching Physician Billing Policy pertains to services involving teaching physicians, residents and/or fellows; it does not apply to the supervision and documentation requirements for services provided by mid-level providers such as nurse practitioners and physician assistants. It also does not apply to services involving medical students.

Midlevel Providers (i.e. nurse practitioners, physician assistants, etc.)
Each third party payor has specific billing guidance associated with services provided by mid-level providers. The physical presence and documentation requirement associated with the Teaching Physician Billing Rules must not be applied to supervision of mid-level providers.
Medical Student Documentation
The only documentation by medical students that may be used by a resident or TP to support a billed service is the medical student documentation of the review of system (ROS) and past family social history (PFSH). The medical student’s documentation of physical exam findings or medical decision making can not be used to support a billable service. The TP must verify and re-document the history of present illness (HPI), as well as, perform and re-document the physical exam and medical decision making activities of the visit. Therefore medical student documentation may be used similar to documentation provided by nursing staff, other students, and/or patients themselves.

You have completed the review of the Teaching Physician Billing Policy Continuing Education Program. To fulfill the education requirement you must satisfactorily complete an exam, which can be accessed now by clicking on Take Exam. You must achieve a score of 11 (out of 15) or higher to successfully complete this mandatory education requirement. You can re-take the exam as many times as necessary to achieve a passing score.

Upon completing the exam, you will be notified of your results and will be given an explanation for each incorrect answer. Your score will be forwarded to the Joint Office for Compliance. You will receive an email response acknowledging your completion of this exam. The Iowa City VAMC will be notified of the satisfactory completion of this education program for teaching physicians who also have clinical privileges at the VAMC.

If you have any questions contact your department compliance liaison or one of the staff in the Joint Office for Compliance.

University of Iowa, Roy J. and Lucille A. Carver College of Medicine, 200 CMAB, Iowa City, IA, 52242, 319-335-6707

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