The Centers for Medicare and Medicaid Services (CMS) guidelines for Teaching Physicians, Interns and Residents (2017) are specifically directed to the role of the teaching physician, although
they can be applied to teaching nurse practitioners who care for Medicare patients. The CMS guidelines and NTF criteria for the ratio of preceptor to student are reasonable and explicitly state: As an expert clinical practitioner, the preceptor has mastered a variety of ways of
thinking that contribute to the process of clinical reasoning. Teaching the student how to use these ways of thinking helps. The process of teaching clinical reasoning guides the student in learning new ways of thinking in clinical practice. Students should be asked to:Next Section:
Teaching physician services refers to physicians teaching interns, residents, and medical students during patient treatment. The Centers for Medicare & Medicaid Services (CMS) outlines the regulations associated with these services and the requirements for maintaining compliance with the regulations in the Medicare Claims Processing Manual, Chapter 12. If you submit claims as a teaching physician, it is your responsibility to know and adhere to these
rules. The Medicare Claims Processing Manual, Chapter 12 contains the Calendar year 2022 changes to Medicare Part B Payment Policies Final Rule (CMS-1751-F). E/M visit billing information for teaching physicians has been updated. Key Changes IOM 100-04, Chap. 12 General Category Things to Know Section 100.1.1 Exception for E/M Services Furnished in Certain Primary Care Centers Effective January 1, 2022, teaching physicians may use only medical decision making (MDM) for purposes of E/M visit level selection when billing the Medicare program under the physician fee schedule for office/outpatient E/M visits under this primary care exception. Section 100.1.4 Timed-Based Codes Office/outpatient E/M visit codes for which total time is used for the visit level selection. For purposes of selecting visit level, only count time spent by the teaching physician performing qualifying activities listed by CPT (with or without direct patient contact on the date of the encounter), including the time the teaching physician is present when the resident is performing such activities. When billing E/M services as a teaching physician you must personally document, at a minimum, the following: This may be supported by entries in the medical record made by the students, residents, nurses or the teaching physician.
However, the teaching physician must verify in the medical record all student documentation or findings. Also, the teaching physician must personally perform (or reperform) the physical exam and medical decision making activities of the E/M service being billed, but verification of student documentation in the medical record is allowed, rather than redocumenting this work. Exception for E/M Services Furnished in Certain Primary Care Centers Under this exception, teaching physicians may submit claims for services
furnished by residents in the absence of a teaching physician for the following services: New Patient Established Patient 99202 99211 99203 99212 99213 Also included under the primary care exception are HCPCS codes G0402, G0438 and G0439. Residents providing the billable patient care service without the physical presence of a teaching physician must have completed at least six months of a GME approved residency program. Teaching physicians submitting claims under this exception may not supervise more than four residents at any given time and must direct the care from a proximity that enables immediate
availability. For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. For services in this category, do not add time spent by the resident in the absence of the teaching physician. For E/M codes in which counseling and/or coordination of care comprises more than 50 percent of the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service, only count
time spent by the teaching physician performing qualifying activities, including the time the teaching physician is present when the resident is performing such activities. For more information on the requirements and restrictions of the Primary Care Exemption, refer to 42 CFR 413.78(e)(3)(ii), 42 CFR 413.79(a)(6) and Publication 100-04 Medicare Claims Processing Manual, Chapter 12, Section 100.1.1. References
(visit CMS.GOV for additional information)
When providing E/M services
under a program (GME) granted a primary care exception, teaching physicians may bill Medicare for certain E/M services provided by residents. However, effective January 1, 2022, teaching physicians must use medical decision making (MDM) for purposes of E/M visit level selection when billing the Medicare program under the physician fee schedule for office/outpatient E/M visits under this primary care exception.