Evaluation and Management

Teaching Environment E/M Services

Please define levels of care for E/M services that can be performed by residents in a hospital outpatient setting under the PCE rules.

Answer: CMS PCE guidelines for the hospital outpatient setting permit a resident who has completed at least six months of training to perform a low‑mid level E/M service under the direct supervision of a TP. The TP must be physically available within the suite, without other simultaneous responsibility and be responsible for supervising no more than four residents per session. The resident’s services may be represented by CPT codes 99201–99203 and 99211–99213. PCE guidelines also permit the resident to perform the IPPE and AWVs.

CMS limited the PCE levels of care in recognition of the resident’s status as a physician-in-training and the medical necessity of the teaching physician’s role in evaluating and managing clinical problems that demand a more detailed or comprehensive level of care. In the event that a resident identifies the need for a detailed or comprehensive service, he/she must request the teaching physician’s personal supervision and documented presence in order to support the higher-level service as billable to Medicare.

Please explain CY 2024 guidelines for telehealth services furnished in a teaching setttng.

Answer: The following guidelines apply in the teaching setting:
- Teaching physicians may perform services personally.
- Residents may perform the services when the teaching physician is physically present for the key service elements.
- In residency training sites outside of MSAs, teaching physicians may provide virtual supervision for residents’ services performed either in person or via telehealth.
- Through CY 2024, in all residency training sites, teaching physicians may provide virtual, audio-visual supervision for telehealth services performed by residents.
- In the primary care exception setting, supervising teaching physicians may bill for lower and mid-level services provided by residents.
When level-setting a service based on time, is time spent alone by a resident added to time spent by the teaching physician and counted in total time spent?

Answer: When level-setting a services based on time, only time spent by an enrolled Medicare provider who is permitted to perform and bill for an E/M service is counted toward total time spent. This limits counted time to time spent by a physician or NPP (PA or NPP). Clinical staff time cannot be counted and, in this context, the resident’s time would be considered as clinical staff time and is not counted.

Is a teaching physician's attestation on a discharge summary adequate to support the service?

Answer: Discharge services (CPTs 99238–99239) are time based codes. When a teaching physician performs a discharge service, he/she must be present for the entire period represented by the code being billed. If a resident participates in the discharge service, the resident’s time is not counted. The resident may participate and document the service and the teaching physician may add an attestation, but the teaching physician’s attestation must include a statement that the teaching physician was present for the full time period defined by the code

As per CMS Internet-only-Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 100.1.4; Time-Based Codes (Rev. 1128; Issued: 3/4/2022; Effective: 1/1/2022; Implementation: 5/15/2022) 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 example, a code that specifically describes a service of from 20 to 30 minutes may be paid only if the teaching physician is physically present for 20 to 30 minutes. Do not add time spent by the resident in the absence of the teaching physician to time spent by the resident and teaching physician with the beneficiary or time spent by the teaching physician alone with the beneficiary. Examples of codes falling into this category include:

Individual medical psychotherapy (HCPCS codes 90804–90829)
Critical care services (CPT codes 99291–99292)
Hospital discharge day management (CPT codes 99238–99239)

Please define what time of night qualifies as a “late night admission” for teaching physician billing.

Answer:CMS does not define a specific time for “late at night.” Reasonably speaking, a late admission may be a patient admitted to the hospital by a resident, late on a given day and not seen until the subsequent day by the attending teaching physician. The attending physician’s note should include an explanation for his/her service taking place on the day after the patient was admitted to inpatient status.

In a teaching facility, if a provider uses the GC modifier should the resident enter documentation in the medical records as well? Or is the GC modifier enough to show that the resident was involved in the care? What is expected in the documentation?

Answer: The resident should document his/her portion of the service and the attending physician should either write a separate note or fulfill the documentation requirement by entering an attestation to the resident’s note. In both scenarios, documentation must support the level of care billed.

Is it permissible for a student physician or student NP to document a ROS and/or PFSH?

Answer: While it’s permissible for a student physician or student NP to elicit and document a PFSH and/or ROS, the supervising physician or NP needs to review and corroborate that information, as well as perform the remainder of the E/M visit, in order to bill the service to Medicare. Medicare payment is based on work performed by the attending/billing provider, not on work performed by a student.

In a PCE environment, can a physician supervise residents while also acting as the lead triage for nursing staff?

Answer: The supervising physician may not have other responsibilities while supervising residents in a primary care exception environment. Acting as a triage for nursing staff would be considered a separate responsibility and, as such, would not be permissible.

Some graduate training programs may require residents to spend two‑three weeks in a primary care setting. Is this allowable under the PCE guidelines?

Answer: In order to comply with PCE rules, the assigned primary care service site must be located in a hospital or other ambulatory care outpatient setting. PCE rules do not allow for physician supervision of residents in the office or home visit setting. Please refer to the information provided in MLN Booklet® Guidelines for Teaching Physicians, Interns, and Residents.

When a TP in a PCE environment sees a patient with the resident, is that service within PCE guidelines?

Answer: The TP may see clinic patients at the request of a resident, while still fulfilling the supervisory expectation, as long as the TP remains fully available to other residents who are seeing clinic patients at the same time.

In the attestation from the TP, must the TP document separately and give comments on the resident’s note? Would it be sufficient if the TP simply states that he/she saw and evaluated the patient and agreed with the resident’s documentation, findings and POC?

Answer: While the entry described above meets the minimal expectation for a TP, NGS encourages documentation of clinical details that can further substantiate the TP’s presence and full participation in the E/M service. For example: “Patient seen and examined with Dr. Smith. Agree with his finding of aortic murmur and plan for echocardiogram later today.” These details enhance the accuracy of the medical record and will substantiate the service during a possible subsequent Medical Review audit.
Please define the use of time in level setting a service in a primary care exception (PCE) outpatient setting.

Answer: Time may not be used to level set a service in the PCE setting. CMS has confirmed in MLN Matters® MM12519: Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List medical decision making is the sole basis for level setting an E/M service in the PCE setting.

Reviewed 10/8/2024