Documentation Tips

Residents in a Teaching Setting (Medicare)

Documentation Tips: Residents in a Teaching Setting – Medicare

Medicare defines a Resident as an individual who participates in an approved graduate medical education (GME) program or a physician who is an approved GME fellowship program.  A medical student is never considered to be an intern or resident and no service furnished by a medical student qualifies as a billable service under Medicare.

In general, Medicare will pay for physician services furnished in a teaching setting under the physician fee schedule only if the services are furnished:

  • Personally by a teaching physician who is not a resident.
  • By a resident seeing a patient in the “physical presence” of a teaching physician who documents his or her presence during the performance of the critical or key portions of the service and discussion of the case with the resident.
  • Jointly by a teaching physician and a resident, seeing the patient at different times during a visit, provided the teaching physician independently performs the critical or key portions of the service and documents discussion of the case with the resident.
  • When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day.

For purposes of payment, the teaching physician must at a minimum enter a personal notation documenting his or her performance of and/or physical presence during the key or critical portions of the service.  As defined by CMS, critical or key portion means “that part (or parts) of a service that the teaching physician determines is (are) a critical or key portions.”

For minor surgical procedures (lasting less than five minutes), the teaching physician must be physically present during the entire service. For major procedures (lasting more than five minutes), the teaching physician must be physically present during the “key portion(s)” of the service and must be immediately available to furnish service during the entire procedure. The teaching physician must document the extent of his/her participation.

Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services.  Time spent teaching may not be counted towards critical care time.  Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted when reporting a time based code.

Medicare pays for the interpretation of diagnostic radiology and other diagnostic test if the interpretation is performed by or reviewed with a teaching physician. If the teaching physician’s signature is the only signature on the interpretation, Medicare assumes that he/she is indicating that he/she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the resident’s interpretation and either agrees with it or edits the findings. Medicare does not pay for an interpretation if the teaching physician only countersigns the resident’s interpretation.

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