FREQUENTLY ASKED QUESTIONS

• Teaching Physician Rule as it Applies to E/M Services
• Anesthesiology - Single Cases With Residents
• Diagnostic Coding
• Emergency Department Services
• Endoscopic Procedures
• Observation Services
• Pathology Services
• Primary Care Exception
• Radiology and Other Diagnostic Tests
• Surgical Services

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Teaching Physician Rule as it Applies to E/M Services

Q: What if the physician cannot identify the key portion of a service for which payment is sought?
A: Then the teaching physician must be present for the entire service.

Q: Are medical students considered "ancillary personnel?"
A: Medical students do not count as residents, but are considered to be ancillary personnel.

Q: Since a teaching physician can perform service(s) faster than a resident, is that a factor in determining the CPT code to use?
A: No. Time does not determine level of code in most instances.

Q: Is using only the word "agree" acceptable as teaching physician documentation?
A: No. Using only the word "Agree" is not acceptable because physical presence and level of involvement could not be determined. The use of standard language is recommended. For example: "I personally performed the (insert visit, consultation) service."
or
"Dr. Armstrong was present during or directly observed the (identify key portion of service) provided." (Key portions may include the exam, history taking, and/or medical decision-making process.)

Q: Must the teaching physician personally document the key portion of the service or may the resident or nurse enter the note?
A: The teaching physician must be present during the key portion of the service(s) and a personal note by the teaching physician must be entered in the record to verify presence.

Q: How should the teaching physician document his/her presence during the portion of the service that determines the level of service billed?
A: A personal notation by the teaching physician must be entered in the medical record documenting presence during the two or three required components demonstrating the level of care given.

Q: If the teaching physician determines the key portion of the service to be medical decision making, does the teaching physician need to be present at the time of the patient's exam, or will documentation or discussion of the patient's case satisfy the requirement?
A: The teaching physician's presence and participation must be documented by a personal entry in the medical record. Discussion of the case with the resident, after the fact, is considered supervision and is not billable, except for services provided in a Primary Care Exception area.

Q: Are emergency department teaching physician requirements the same as all other E/M services (i.e., are ER physicians exempt from providing the key portion of every service billed)?
A: The ER teaching physician must participate in and identify the key portion of all services provided in the ER.

Q: Is the following note sufficient to document a billable service? "Patient seen and examined by me."
A: No. The teaching physician must state the key portion of each component within the level of service for which payment is sought.

Anesthesiology - Single Cases with Residents

Q: Must the teaching physician document his/her time in and time out during the critical points of the procedure?
A: A time in, time out record does not have to be kept for this purpose; however, time is a key component utilized in the charge calculation.

Q: Must a teaching anesthesiologist personally document presence during induction, emergence, and any other portion of the procedure?
A: The teaching anesthesiologist must personally document presence during the critical or key portion(s) as well as the induction and emergence portions of the procedure. The critical or key portion(s) must be identified and the teaching anesthesiologist must also state in the medical record their immediate availability during the entire procedure.

Diagnostic Coding

Q: If I perform a chest x-ray on an asymptomatic patient as part of a physical exam and find a nodule, do I submit the bill with the diagnosis of "nodule."
A: No. The x-ray must be coded with the appropriate ICD-9-CM diagnosis code for screening.

Emergency Department Services

Q: If I am asked to evaluate my patient by the ED physician to advise him/her whether or not to admit the patient to the hospital, how should I bill my services?
A. This depends on the individual situation. According to the carriers manual, if the patient is admitted to the hospital by the patient's personal physician, then the patient's regular physician should bill only the appropriate level of initial hospital care, because all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The emergency department physician who saw the patient in the emergency department should bill the appropriate level of emergency department codes.

OR:

A. If the emergency department physician, based on the advice of the patient's personal physician who came to the emergency department to see the patient, sends the patient home, then the emergency department physician should bill the appropriate level of emergency department service. The patient's personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. The patient's personal physician would not bill a consultation because he or she is not providing information to the emergency department physician for his or her use in treating the patient. If the patient's personal physician does not come to the hospital to see the patient, but only advised the emergency department physician by telephone, then the patient's personal physician may not bill.

Endoscopic Procedures

Q: Are "time in" and "time out" statements required?
A: There is no requirement for "time in" and "time out" records. It may be helpful, however, for record-keeping purposes.

Observation Services

Q: What types of services would/would not qualify for outpatient observation?
A: There must be medical necessity of observation services and the medical necessity must be documented in the medical record. Routine stays following late surgery, diagnostic testing, or outpatient therapy/procedures may not be billed as observation unless there is documentation that the patient's condition is unstable. Normal postoperative recovery time following surgery cannot be billed as an outpatient observation.

Q: When should observation orders be written?
A: Physician orders for outpatient observation must be written prior to the initiation of observation services. Orders may not be backdated.

Q: If a hospital determines within a short period of time after admitting a patient that although the patient was acute upon admission, he/she has responded rapidly to treatment and is no longer acute, should the hospital bill the stay as an outpatient observation to prevent denial of a short stay/medically unnecessary admission?
A: No. An inpatient admission cannot be downgraded to outpatient observation. Hospitals, peer review organizations, etc. should not apply "hindsight" in determining medical necessity of admission. If, in the judgment of the admitting physician, a patient has an acute condition that requires treatment in an inpatient setting at the time of admission, the physician should document this in the medical record. If the patient should respond more rapidly to treatment than was anticipated, this should also be documented. The medical record documentation will allow an outside reviewer to determine what the physician was thinking at the time of admission and understand that medical necessity for inpatient admission was present.

Q: If a hospital determines after admitting a patient that he/she was not acute at the time of admission, should the hospital bill the stay as an outpatient observation?
A: Again, an inpatient admission cannot be downgraded to outpatient observation. Should a hospital determine after admission that the indications for inpatient admission were never present (e.g., the patient did not have a condition requiring hospitalization at the time of admission), the inpatient admission should be billed provider liable.

Q: If an intern admits a patient as an inpatient and then the staff attending physician determines that the patient should be cared for in outpatient observation, can the attending physician change the order from inpatient admission to outpatient observation, and can the case then be billed as an observation case?
A: No. If interns at a hospital have privileges to admit patients, and there is a question about medical necessity, the order for the admission should be clarified with the intern at the time of admission. If the patient has already been admitted, and medical necessity was not present at the time of admission, the stay should be billed as an inpatient admission, provider liable. If interns do not have the privilege to admit patients, they should not be allowed to write admission orders and the hospital should not accept admission orders from them.

Q: There is no difference in the care rendered in many hospitals in terms of outpatient observation versus inpatient admission. The patient may be placed in the same bed and the only difference is in how the services are billed. Since the only real change in correcting the physician's order or the level of care being rendered in many situations is "on paper," why can't the status be changed retrospectively?
A: The fact that movement of the patient from outpatient observation to inpatient level of care is transparent in some facilities does not change the prohibition against altering the physician's patient status order or moving the patient from inpatient level of care to outpatient observation after-the-fact. The physician is responsible for determining the level of services required for patients when they enter a hospital. Although some hospitals may choose to provide the same level of care in outpatient observation as they provide in inpatient care, they are actually two distinctly different levels of care that result in different types of reimbursement and, in many hospitals, the care may be quite different.

Q: If a physician writes a clear admission or outpatient observation order and the patient is receiving the level of care ordered, but an error by the business office or other staff results in an incorrect level of care designation being noted in the billing system, can this type of clerical transcription or designation error be corrected?
A: A clerical error that involves only an incorrect level of care status being assigned, not a problem with the physician's order or the level of care the patient is receiving, can be corrected so that it is in alignment with the patient's status as ordered by the physician.

Q: Is a physician actually required to write an inpatient admission order when a patient is upgraded from outpatient observation to inpatient admission?
A: Yes, the hospital cannot bill an inpatient admission without a physician order. The order must clearly indicate the level of care required, and documentation in the medical record must support medical necessity of the inpatient admission.

Q: What is "routine recovery time?"
A: Routine recovery time may be different for different procedures. It is the length of time that a patient is observed after a procedure until the patient is stable and can be discharged. This routine recovery time is included in the reimbursement for the procedure. If a patient becomes unstable during the recovery time, he/she may be admitted to outpatient observation for treatment/observation of the acute condition/symptoms.

Pathology Services

Q: What is an example of a billable clinical consultation service?
A. A pathologist telephones a surgeon about a patient's suitability for surgery based on the results of clinical laboratory results. During the course of their conversation, the surgeon asked the pathologist whether, based on test results, patient history and medical records, the patient is a candidate for surgery. The surgeon's request required the pathologist to render a medical judgement and provide a consultation. The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patient's medical record that he/she requested a consultation.

Primary Care Exception

Q: What are the documentation requirements for those E/M codes that fall under the outpatient exception?
A: The teaching physician must personally document in the medical record that the medical history, examination, diagnosis, tests, etc. performed/written by the resident were reviewed during or immediately after the visit, and he/she must specify the extent of participation in the review and the direction of the services furnished to the patient.

Q: Can the teaching physician supervise one or two residents and have private patients of their own scheduled at the same time?
A: No. For the PCE rule to apply, the teaching physician is to function in a teaching capacity only and may have no other concurrent duties.

Q: I am supervising four residents on PCE. One is seeing a patient who is complex; I go in and see and examine the patient and document my involvement, and we bill for a level 4 or 5 visit. During this time I am certainly available for any urgency/emergency from another resident. Is there any reason that I can't bill for this level 4 or 5 visit and still maintain the PCE for the other three residents?
A: As long as the more complex service is unscheduled, you may continue to bill for other level 1, 2, and 3 E/M services furnished by up to four residents during clinic session. However, it is important to remember that you must revert to the physical presence rule in order to meet billing guidelines.

Radiology & Other Diagnostic Tests

Q. What constitutes an interpretation and written report?
A: A notation in the medical records saying "fx-tibia" or "EKG-normal" would not suffice as a separately billable interpretation and report of the procedure. Such a notation would indicate only a review of the findings, not an interpretation and report. An "interpretation and report" should address the findings, relevant clinical issues, and applicable comparative data.

Q. How does Medicare decide which claim to pay if two radiology claims are received?
A: If one service is for an interpretation by the treating physician in the emergency department for the purpose of ruling out one condition (e.g., pneumonia), and the second service is the radiologist's separate interpretation of that same film for a different condition (e.g., to evaluate a suspicious nodule that the ER physician had seen), both services are billable. One of the services will be appended with a modifier - 77.

Surgical Services

Q: If a resident performs a surgical procedure during the middle of the night, without the presence of a teaching physician, could the follow-up visits be billed if the teaching surgeon is present for these visits? (A global surgery fee was not billed because the teaching surgeon was not present when the procedure was performed.)
A: In this situation, E/M codes could be billed for post surgical visits if the teaching surgeon is present for the visits (the total amount paid for post surgical visits cannot exceed the amount which would be paid for the post surgical portion of the global payment). Further, the visits should be billed with the CPT surgical modifier for postoperative management only (-55).

Q: Must someone, either the operating room nurse or someone else, document the precise times the teaching surgeon was physically present during a procedure?
A: No. A log of "in" and "out" times is not required by HCFA. Notations in the medical record or on the report written by a nurse, resident, or teaching surgeon that are related to a single procedure would satisfy the documentation requirements for physical presence. However, it should never be acceptable for anyone but the teaching surgeon to document the key portions and personal involvement for overlapping procedures.

Q: Can a second teaching surgeon replace the primary teaching surgeon who performed the critical portion of the procedure, and can that second surgeon then satisfy the "immediately available" provision on behalf of the primary surgeon?
A: Yes; however, the second teaching surgeon could not be involved in or immediately available for any other surgical procedure.

Q: While "immediately available," must the teaching surgeon be scrubbed and in the operating room suite?
A: The teaching surgeon must be ready to attend to or return to a surgical procedure during the entire procedure. The teaching physician may become involved in other activities such as preparing for the next procedure as long as the activity would not preclude a return to the procedure in question.

Q: Has HCFA defined "immediately available" in terms of geographic proximity to the operating room?
A: No.