Transcript News Archive Week of September 13, 1999 NY Podiatrists Charged

NYU School of Medicine
Coding and Reimbursement Seminar Series
Documentation, Coding and
Reimbursement Basics
Presented by the Office of Reimbursement Compliance
Gretchen L. Segado, MS, CPC
Director of Reimbursement Compliance
NYU School of Medicine
316 East 30th Street
New York, NY 10016
(212) 263-2446
(212) 263-6645 fax
[email protected]
Agenda for Today
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Fraud & Abuse-why do I need to pay
attention?
Documentation Guidelines
Reimbursement Principles
Establishing Medical Necessity
CPT & ICD-9 Coding
Special Rules for Teaching Physicians
Published On August 31, 2001, Philadelphia Inquirer, The (PA)
Surgeon To Pay Back Medicare Over Billing
A nationally recognized Philadelphia orthopedic surgeon
agreed yesterday to reimburse the government almost $2
million to settle claims that he billed Medicare for work done by
surgical residents and surgical fellows.
In announcing the $1.89 million settlement with Robert
Booth Jr., both the surgeon and the U.S. Attorney's Office said
the government investigation had nothing to do with the quality
of knee and hip replacements and other surgeries performed.
At issue were billings for surgeries performed between
January 1, 1995 and June 30, 1997, at Pennsylvania Hospital.
The government claimed that Booth had billed Medicare for
treatment handled by junior physicians he was training.
Office Audited For Sports
Billing Fumble
A family practice in West Virginia was audited
earlier this month and ordered to pay back
almost $6,000 to its carrier for improper billing
of school sports physicals back in 2000, a
spokesman for the practice said in a statement to
a local television reporter. The practice allegedly
used the wrong codes and received more
reimbursement than it was allowed, a state
health department worker confirmed.
March 5, 2004
PRESS RELEASE
PHYSICIAN PAYS $203,422 TO SETTLE CIVIL FALSE CLAIMS
ACT CHARGES ARISING OUT OF MEDICARE AND MEDICAID
OVERBILLINGS
… Based on its investigation, the United States alleged
that DR. THACKER had overbilled Medicare and
Medicaid, during the period January 1, 1997 to
December 31, 2002, by charging for "consultation"
services that provided higher reimbursement, when she
was actually performing regular patient visits.
According to the United States, DR. THACKER had
done so approximately 1,800 times during this period.
April 2004
In New York, three subjects were sentenced for
their roles in a scheme to defraud the
Government and private insurers. A podiatrist
was sentenced for submitting claims for
services that were either upcoded, not
rendered, or were medically unnecessary. Also
sentenced were two billing clerks who at the
direction of the office manager, submitted
claims that they knew were fraudulent.
“Let the message be very, very clear.
We have made health care fraud a priority
and we will pursue it as vigorously as we can.”
Janet Reno
Attorney General of the
United States
What Is Healthcare Fraud And
Abuse?
Fraud-Intentional deception or
misrepresentation that the individual
knows to be false or does not believe
to be true, and makes, knowing that the
deception could result in unauthorized
benefit to himself or some other
person.
Examples: Incorrect reporting of
diagnosis or procedures to maximize
payments
What Is Healthcare Fraud And
Abuse?
Abuse- an incident or action that is inconsistent with
accepted sound medical, business or fiscal practice.
•
Abuse may directly or indirectly result in unnecessary
costs, improper payment, payment for services that fail
to meet professionally recognized standards of care, or
that are medically unnecessary.
• Examples are billing for services at a higher level than
what is supported by documentation, improper billing
practices and billing a secondary payer as primary.
Government’s Recent
Focus On Fraud
•
•
•
•
General failure to achieve health care
reform and reduce costs through legislation
Medicare Trust Fund is going bankrupt as
Medicare expenditures continue to rise
Politically popular
Aging population
Susceptibility
Susceptibility to fraud and abuse varies by
the method of reimbursement
• Fee for Service (FFS) System - Abuse is from
•
the provision of excessive services
Capitated Contract System - Abuse is from
the provision of too few services provided per
patient
Major Federal Fraud
& Abuse Laws
•
•
•
•
•
•
•
Medicare Anti-Kickback Statute
United States Criminal Code
Federal False Claims Act
Federal Self-Referral Statute (Stark)
HIPAA
Balanced Budget Act (BBA)
Over 50 statutes used to prosecute
Hypothetical
Dr. I is an attending in the Dept. of Internal Medicine.
One of her patients is a 57 year old chronic alcoholic
with multiple medical problems. This patient has been
non-compliant with medications and has been
hospitalized 3 times within the past year. When asked
by Dr. I why she was not taking medications, she said
she can’t afford them. She then asked Dr. I to write all of
her prescriptions in her brother’s name, claiming that he
has medical insurance that will pay for them. Hoping to
avoid further hospitalizations, Dr. I complies with this
request. Does this practice place Dr. I or her patient at
any risk?
Federal Civil False Claims
Act
Elements of a “False Claim” Offense
• submitting or causing to be submitted
a claim for payment to the
government or using a false record to
get a claim approved
• which claim is false and fraudulent
• wherein defendant acted “knowingly”
Federal Civil False Claims Act
(Cont.)
Penalties
• Triple the damage the government
sustains plus $5,000-$13,000 penalty
for each “false claim”
• Penalties can be so enormous that
defendants often choose to settle
rather than risk a negative outcome
in litigation
Federal Civil False Claims Act
(Cont.)
Most Frequent Applications of the False
Claims Statute
• billing for services not rendered
• false cost reports
• upcoding
• double billing
• provision of unnecessary care
(certifying that unneeded services
were “medically necessary”)
Federal Civil False Claims Act
(Cont.)
Advantages for Government in
Prosecuting under this Statute as
opposed to Criminal Prosecution
•
•
•
•
“intent” element easier to prove
burden of proof less than in criminal
prosecution (preponderance of
evidence)
arguably covers broader types of “false”
claims
availability of qui tam prosecutions
Federal Civil False
Claims Act (Cont.)
Qui Tam Actions
•
•
•
qui tam cases can be
brought by any citizen on
behalf of himself and the
government
qui tam case brought by
relator's filing a complaint
under seal with the US
Attorney
complaint must be based
upon an allegation of a “false
claim”
Savvy Seniors on Fraud Patrol
As a result of training senior volunteers to detect and report
fraud, the Administration on Aging (AoA) has recouped almost
$3.7 million since the inception of the Senior Medicare Patrol
Project in 1997. The AoA has trained nearly 35,000 senior
volunteers to watch for offers of free groceries, free testing, or
free screening in exchange for their Medicare business,
numbers, or statements. The volunteers in turn have held over
200,000 educational sessions on fraud, waste, and abuse, and
have trained over one million Medicare beneficiaries. Out of a
total of 23,142 complaints reported by Medicare beneficiaries in
the first five years of the program, the government took action
on 2,312 complaints, and recovered $3,679,644 in Medicare
funds, and more than $77 million to other payors.
(Medicare Compliance Alert, 4/14/03)
Still don’t think you have to
worry?

Check out these web sites:
http://www.quitamonline.com
www.quitam.com
http://www.quackwatch.org/index.html
Hypothetical
Dr. X has a very busy medical practice.
When blood tests are medically indicated
and documented in the patients’ charts,
he refers his patients to Vampire
Laboratories for testing. Vampire is
owned by Dr. X’s brother.
Is this a problem?
The Federal Self-Referral
Statute (the “Stark Law”)
• a physician may not make a referral
• to an entity for the provision of a designated
•
•
health service for which Medicare payment may
be made, and the entity may not present a claim
for such referral
if the physician or an immediate family member
has a financial relationship with such entity
unless the referral or the financial relationship is
excepted under the statute.
Designated Health Services Under
Stark

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clinical laboratory
services
physical therapy
services
occupational therapy
services
radiology services
radiation therapy
services and supplies
durable medical
equipment and supplies



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
parental and enteral
nutrients, equipment
and supplies
prosthetics, orthotics,
and prosthetic devices
and supplies
home health services
outpatient prescription
drugs
inpatient and outpatient
hospital services
The Stark Law (Cont.)
Penalties
•
•
•
•
Civil monetary penalties of up to $15,000 for each
service rendered in violation of Stark II if the
payment is not refunded on a timely basis
An assessment of not more than twice the amount
claimed for each service that was the basis for the
civil monetary penalty
Exclusion from Medicare and Medicaid
The total refund of Medicare/Medicaid dollars
Medicare Anti-Kickback Statute
•
Key Elements
• “whoever”
• “knowingly and willfully”
• “offers or pays, solicits or receives any
remuneration” in return for
• “referring an individual for the furnishing of any claim
or service or purchasing, leasing or arranging or
recommending the purchase, lease etc., of any item
for service paid for in whole or in part under
Medicare or Medicaid”
• “shall be guilty of a felony.”
Medicare Anti-Kickback Statute
(cont.)
•
Penalties
• Up to five years imprisonment and/or a fine of
•
•
up to $25,000
Exclusion by DHHS from participation in the
Medicare and Medicaid Programs
New penalty under BBA - civil monetary
penalty of $50,000 per violation plus triple
damages
Medicare Anti-Kickback Statute
(cont.)
Safe Harbors
• Types of payments and business
•
•
arrangements between providers that the US
Attorney and the OIG will not prosecute
If a transaction satisfies the elements of a
safe harbor, it will not be grounds for
prosecution regardless of intent.
There are also safe harbors for managed care
arrangements.
Medicare Anti-Kickback Statute
(cont.)
Examples of Safe Harbors
• investments in public companies
• investments in small businesses
• space rentals
• equipment rentals
• warranties
• certain discount arrangements
• employment
• sale of professional practices
Key Distinctions Between the Stark Law
and the Anti-Kickback Statute
•
•
•
Stark applies only to physicians; Anti-Kickback
law applies to all providers
Stark is a strict liability law -- no intent needed;
Anti-Kickback law contains an intent element
Stark is not a criminal statute; Anti-Kickback
law is a criminal statute
Ø Billing Insurance Only!

ROUTINE WAIVER OF DEDUCTIBLES,
COINSURANCE/COPAYMENTS IS
UNLAWFUL

May subject physicians to False Claims Act or
Anti-Kickback liability
Patient’s “cost-share” deters program overutilization
OIG has issued a special Fraud Alert on this
issue


Routine waiver of the deductible/copay can
be construed as a misstatement of the actual
charge
• Example: Provider’s charge is $100 for
service. Medicare pays 80% or $80. If
actual charge is misstated, Medicare is
paying $16 more for the service than is
should be. (Medicare should pay 80% of
$80, not 80% of $100)
The Health Insurance Portability and
Accountability Act of 1996
What’s the fuss over HIPAA?

Privacy rights have become the subject
of national debate
• Increased internet usage has spawned horror
•

stories of “Big Brother” watching
Fear that one click can transmit private info all
over the world
HIPAA made Healthcare Fraud & Abuse
a crime
The 1996 Health Insurance Portability
and Accountability Act (“HIPAA”)
HIPAA’s effect on existing health care fraud and
abuse laws:
• increases resources available for combating fraud
•
•
and abuse
kickback statute expanded to apply to all federal
healthcare payors (e.g.. CHAMPUS)
extends and increases civil monetary penalties
Overview of the HIPAA Privacy Regulations



The HIPAA Privacy Regulations apply to
covered entities’ handling of protected health
information (“PHI”)
The Basic Rule: PHI may not be used or
disclosed by a covered entity except as
specifically required or permitted by the HIPAA
Privacy Regulations.
The standard for PHI to be “de-identified” is
very high, so the HIPAA Privacy Regulations
apply to almost all information regarding a
patient.
Balanced Budget Act of 1997
Gave Government additional Health Care
Fraud & Abuse Measures
• permanent exclusion for those convicted of
•
•
three health care related crimes
authority to refuse to enter into Medicare
contracts with individuals or entities convicted
of felonies
imposition of more civil monetary penalties
Did You Ever Read The Back Of
A HCFA Form?
Every health insurance claim form (HCFA 1500) includes a
certification that all statements made on the form are true
and complete, and that any person who knowingly files a
statement of claim containing any misrepresentation or
any false or misleading information may be guilty of a
criminal act punishable by law and may be subject to
civil penalties. Additionally, for government payors, each
provider certifies that the services rendered were medically
necessary, were personally furnished by the provider or
furnished by the provider’s employee under the provider’s
personal supervision.
With All These Rules, How Can I
Be Safe?



Be familiar with the
laws governing
health care
Document everything
you do and the
reason for doing it
Learn how to code
your services
correctly
General Principles Of Medical
Record Documentation




Complete medical records for each
patient
Make all entries in ink
Use drawings, illustrations & pictures
when appropriate
Write legibly
General Principles Of Medical
Record Documentation
For each encounter:
• reason for the encounter and relevant history,
exam and prior diagnostic test results
• assessment, clinical impression or diagnosis
• plan of care
• date and legible identity of the observer
General Documentation
(Continued)

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Make entries promptly
Do not leave blank spaces
in the patient records
Document relevant
conversations between
patient, responsible
parties, physicians and
staff
Use standard
abbreviations
Basics of Medical
Reimbursement
Payers are willing to pay for services provided they
are:
•covered within the patient’s policy
•medically appropriate for the patient's condition
•medically necessary
•coded correctly
Covered services are those services:
•defined as “covered” within the terms of the
patient's benefit plan
•documented in the medical record
medically necessary
Variables That Affect
Reimbursement Include:

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

Individual insurance policies and
regulations
Patient’s coverage
Federal regulations
Contractual agreements
Accuracy of diagnosis and procedure
coding
Physician office systems
Establishing Medical Necessity



The physician’s record should clearly
document the medical necessity for all
services rendered.
Only clinically proven, effective procedures
are reimbursable under the Medicare
program
Appropriate procedural and diagnosis coding
is the key to establishing medical necessity
What Is CPT-4?

Systematic listing of procedures & services
performed by physicians

Five-digit codes for procedures or services

Used to describe the physician’s services to a
patient for diagnosis and treatment of the medical
condition(s)

Codes and descriptive terminology developed and
copyrighted by AMA CPT Editorial Panel
What is ICD-9?



Translates written terminology or
descriptions into universal numeric
and alphanumeric codes that can be
processed electronically
Conveys a patient’s clinical picture to
third-party payers
Serve to establish the medical
necessity for the resultant
procedures, treatment and medical
supplies
Linkage Between ICD-9 & CPT
(Continued)

CPT-4 represents the “WHAT” was done to the patient
Procedure------------------- 93010 (EKG)

ICD-9 represents the “WHY” it was done
Medical Necessity--------- 786.50
(Chest Pain)
Diagnosis (ICD-9 CM) Coding

While it is important to include differential
diagnosis, suspected conditions or “ruleouts” in the medical documentation, an
ICD-9 code is never selected based on
what is being “ruled-out”. No such ruleout codes exist.
• i.e. no code for rule-out MI

Use signs and symptoms or established
diagnosis on billing forms
Together, the correct CPT code and
and diagnosis code establish the
medical necessity
Diagnostic studies
• X-ray, US, labs, etc.
• without established
diagnosis (i.e., rule out,
probable, suspected)
Example:
Diagnostic Study:
Pelvic Ultrasound
for R/O Ectopic Pregnancy
ICD-9-CM
Report signs &
symptoms
ICD-9 Linkage:
pelvic pain
(625.9)
Medical Necessity (continued)
Diagnostic studies with
confirmed or established
diagnosis
Example:
Diagnostic Study:
Pt. for Pelvic Ultrasound
Report confirmed
or established
diagnosis
ICD-9 Linkage
uterine fibroid
(218.9)
Organization Of CPT Manual
• Text organized in 6 major sections
• Evaluation and Management ( 99201 - 99499)
• Anesthesiology ( 00100 - 01999,
99100 - 99140)
• Surgery ( 10040 - 69990)
• Radiology ( 70010 - 79999)
• Pathology and Laboratory ( 80049 - 89399)
• Medicine ( 90281 - 99199)
Format Of The CPT-4 Manual


Developed as a stand-alone descriptions of the
procedures
To conserve space, some are not printed in their
entirety but refer back to a common portion listed in
a preceding entry
EXAMPLE:
25100
Arthrotomy, wrist joint; for biopsy
25105
for synovectomy
25105
Arthrotomy, wrist joint; for
synovectomy
History of
Medicare’s Teaching Physician Rules
• Federal government payment rules
• First billing guidelines established in 1967
• Revisited and the birth of Intermediary Letter 372
(IL 372)
• Continued confusion
• Lack of standard application of rules by local
Medicare Carriers
• Many institutions paid fines related to Teaching
Physician Rules
• University of Pennsylvania- $30 million
• University of Pittsburgh- $19 Million
• Thomas Jefferson University- $12 million
Johns Hopkins Settles for $800,000
In February 2003 the Office of Inspector General (OIG) released a
bulletin stating that Johns Hopkins University (JHU) had entered into
an $800,000 settlement with the federal government to resolve
charges of fraudulent Medicare billing. Under the Physicians at
Teaching Hospitals (PATH) initiative, the OIG performed audits of
teaching physician services at Johns Hopkins from 1/1/94 through
12/31/94. According to the OIG audit, Johns Hopkins submitted false
claims to Medicare on behalf of faculty physicians for services that
were actually provided by interns and residents. Documentation did
not support that the teaching physicians were personally
involved in the services provided.
Nephrologist at University of
Washington Pleads Guilty
Another teaching physician at the University of Washington (UW) in
Seattle has pleaded guilty to submitting false claims to Medicare and
Medicaid. Dr. William Couser, ex-Chief of Nephrology, has been
accused of billing for renal dialysis services that were actually
performed by residents but billed in his name. The accusations stem
from a qui tam suit filed in 1999 that brought allegations against three
departments at UW: neurosurgery, nephrology, and radiology..…
During the federal investigation at UW, which lasted four years, the
government examined more than a million documents and issued
more than 100 subpoenas. The university spent over $10 million in
legal fees, and in addition, has spent $1 million annually on
compliance efforts since the suit was filed. The civil investigation is not
yet resolved but is expected to conclude quickly. Civil monetary
penalties are likely to be in the tens of millions.
What are the Laws that Govern Teaching
Physician Rules?
42 CFR §415.172 (a)
General rule. If a resident participates in a service furnished in a
teaching setting, physician fee schedule payment is made only if a
teaching physician is present during the key portion of any service
or procedure for which payment is sought.
42 CFR §415.172 (a)(2)
In the case of evaluation and management services, the teaching
physician must be present during the portion of the service that
determines the level of service billed.
What are the Laws that Govern Teaching
Physician Rules?
42 CFR §415.172 (b)
The medical records must document the teaching physician was present
at the time the service is furnished. The presence of the teaching
physician during procedures may be demonstrated by the notes in the
medical records made by a physician, resident, or nurse. In the case of
evaluation and management procedures, the teaching physician must
personally document his or her participation in the service in the medical
records.
42 CFR §415.172 (c)
In the case of services such as evaluation and management for which
there are several levels of service codes available for reporting purposes,
the appropriate payment level must reflect the extent and complexity of
the service when fully furnished by the teaching physician.
Presence & Participation
• The two significant principles of teaching
physician documentation are presence &
participation.
• Presence may not be inferred;
it must be
stated or “attested” by the teaching physician.
Presence is defined in the teaching physician
guidelines.
Medicare’s Teaching Physician Rules
Important Definitions:

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

Resident - an individual in an approved graduate medical education
(GME) program or a physician who is authorized to practice only in a
hospital setting..
Teaching physician - physician (other than another resident) who
involves residents in the care of his or her patients.
Direct medical and surgical services- services to individual patients
that are either personally furnished by a physician or furnished by a
resident under the supervision of a physician in a teaching hospital
Physically present - located in the same room (or partitioned or
curtained area, if the room is subdivided to accommodate multiple
patients) as the patient and/or performs a face-to-face service.
Critical or key portion - that part (or parts) of a service that the
teaching physician determines is (are) a critical or key portion(s).
These terms are interchangeable.
Teaching Physician Rules for
Evaluation & Management Services
The teaching physician must personally document
at least the following:
 That they performed the service or were physically
present during the key or critical portions of the service
when performed by a resident.
 The participation of the teaching physician in the
management of the patient.
Reviewers will combine the documentation of both the
resident and the physician.
Teaching Physician Rules for
Evaluation & Management Services
•
•
Documentation by the resident of the presence and
participation of the teaching physician is not sufficient
to establish the presence and participation of the
teaching physician for an Evaluation & Management
service.
The combined entries into the medical record by the
TP and the resident must support the medical
necessity of the service.
What Are The Most Recent Changes To
The Teaching Physician Requirements?

For E/M services, it is no longer required that the TP
document a patient-specific comment related to the
history, exam, and medical decision making as
required by the code category.

The requirements for TP presence during the critical
and key portions of both E/M services and surgical
procedures has not changed.

Physicians now have specific examples of minimally
acceptable documentation for common E/M
scenarios.
To Whom Do these Rules Apply?
These guidelines apply to medical residents only, those
individuals with an M.D. or D.O. degree that meet the
definition of a resident. These guidelines do not apply to any
other health care service provider other than teaching
physicians and residents.
•
•
•
•
They do not apply to any kind of student: Nursing, PA,
Nurse Practitioner Psychology or otherwise.
They do not apply to Advance Practice Nurses or
Physician’s Assistants
They do not apply to nurses.
They do not apply to anyone else other than those
individuals meeting the definition of a medical resident.
Scenario 1



Teaching physician personally performs all the
required elements of an E/M service without a
resident.
Where a resident has written notes, the
teaching physician's note may reference the
resident's note.
Teaching physician must document that s/he
performed the critical or key portion(s) of the
service and that s/he was directly involved in
the management of the patient.
Acceptable Documentation for
Scenario 1

Admitting Note: "I performed a history and physical examination
of the patient and discussed his management with the resident.
I reviewed the resident's note and agree with the documented
findings and plan of care."

Follow-up Visit: "Hospital Day #5. I saw and examined the
patient. I agree with the resident's note except the heart
murmur is louder, so I will obtain an echo to evaluate."

If there are no resident notes, the teaching physician must
document as he/she would document an E/M service in a nonteaching setting.)
Scenario 2



Resident performs the elements required for
an E/M service in the presence of, or jointly
with, the teaching physician and the resident
documents the service.
Teaching physician must document that he or
she was present during the performance of the
critical or key portion(s) of the service and that
he or she was directly involved in the
management of the patient.
Teaching physician's note should reference the
resident's note.
Acceptable documentation for
Scenario 2


Initial or Follow-up Visit: "I was present
with resident during the history and
exam. I discussed the case with the
resident and agree with the findings and
plan as documented in the resident's
note."
Follow-up Visit: "I saw the patient with
the resident and agree with the
resident's findings and plan."
Scenario 3




Resident performs some or all of the required elements of
the service in the absence of the teaching physician and
documents his/her service.
Teaching physician independently performs the critical or
key portion(s) of the service with or without the resident
present and, as appropriate, discusses the case with the
resident.
Teaching physician must document that he or she
personally saw the patient, personally performed critical
or key portions of the service, and participated in the
management of the patient.
Teaching physician's note should reference the resident's
note.
Acceptable Documentation for
Scenario 3




Initial Visit: "I saw and evaluated the patient. I reviewed
the resident's note and agree, except that picture is more
consistent with pericarditis than myocardial ischemia. Will
begin NSAIDs."
Initial or Follow-up Visit: "I saw and evaluated the patient.
Discussed with resident and agree with resident's findings
and plan as documented in the resident's note."
Follow-up Visit: "See resident's note for details. I saw and
evaluated the patient and agree with the resident's finding
and plans as written."
Follow-up Visit: "I saw and evaluated the patient. Agree
with resident's note but lower extremities are weaker, now
3/5; MRI of L/S Spine today."
Following are examples of
unacceptable documentation:







"Agree with above.", followed by legible countersignature or
identity;
"Rounded, Reviewed, Agree.", followed by legible
countersignature or identity;
"Discussed with resident. Agree.", followed by legible
countersignature or identity;
"Seen and agree.", followed by legible countersignature or
identity;
"Patient seen and evaluated.", followed by legible
countersignature or identity; and
A legible countersignature or identity alone.
Such documentation is not acceptable, because the
documentation does not make it possible to determine whether
the teaching physician was present, evaluated the patient,
and/or had any involvement with the plan of care.
E/M Service Documentation
Provided By Students



The only part of a student’s documentation that may be
used by the teaching physician is the Review of Systems
and Past Medical, Family and Social History
The teaching physician may not refer to a student's
documentation of physical exam findings or medical
decision making in his or her personal note.
If the medical student documents E/M services, the
teaching physician must verify and redocument the
history of present illness as well as perform and
redocument the physical exam and medical decision
making activities of the service.
Procedures

In order to bill for surgical, high-risk, or other
complex procedures, the teaching physician
must be present during all critical and key
portions of the procedure and be immediately
available to furnish services during the entire
procedure.
TP Documentation of Minor Procedures

The TP must be present for the entire procedure in order to
bill for the service.
• Minor procedures are not defined within CPT, although the
Medicare rule characterizes minor procedures as those
taking only a few minutes to complete (5 min or less).

The documentation may be provided by either the resident, the
nurse or personally by the TP. If the resident provides the
documentation, the attestation may be phrased as follows:
•
•
Dr. TP was present during the entire procedure
Procedure performed with (by) Dr. TP
Surgery (Including
Endoscopic Operations



The teaching surgeon is responsible for the preoperative,
operative, and post-operative care of the beneficiary.
The teaching physician's presence is not required during
the opening and closing of the surgical field unless these
activities are considered to be critical or key portions of the
procedure.
The teaching surgeon determines which post-operative
visits are considered key or critical and require his or her
presence.
Surgery (Including Endoscopic
Operations


During non-critical or non-key portions of the surgery, if the
teaching surgeon is not physically present, he or she must
be immediately available to return to the procedure, i.e., he
or she cannot be performing another procedure.
If circumstances prevent a teaching physician from being
immediately available, then he/she must arrange for
another qualified surgeon to be immediately available to
assist with the procedure, if needed.
Single Surgery


When the teaching surgeon is present for the entire
surgery, his or her presence may be demonstrated by
notes in the medical records made by the physician,
resident, or operating room nurse.
For purposes of this teaching physician policy, there is
no required information that the teaching surgeon must
enter into the medical records.
Two Overlapping Surgeries



In order to bill Medicare for two overlapping
surgeries, the TP must be present during the
critical or key portions of both operations.
Therefore, the critical or key portions may not
take place at the same time.
When all of the key portions of the initial
procedure have been completed, the TP may
begin to become involved in a second
procedure.
The TP must personally document in the
medical record that he/she was physically
present during the critical or key portion(s) of
both procedures
Two Overlapping Surgeries


When a TP is not present during non-critical or nonkey portions of the procedure and is participating in
another surgical procedure, he or she must arrange
for another qualified surgeon to immediately assist
the resident in the other case should the need arise.
In the case of three concurrent surgical
procedures, the role of the TP (but not
anesthesiologist) in each of the cases is classified as
a supervisory service to the hospital rather than a
physician service to an individual patient and is not
payable under the physician fee schedule.
Published On August 31, 2001, Philadelphia Inquirer, The (PA)
Surgeon To Pay Back Medicare Over Billing
A nationally recognized Philadelphia orthopedic surgeon
agreed yesterday to reimburse the government almost $2
million to settle claims that he billed Medicare for work done by
surgical residents and surgical fellows.
In announcing the $1.89 million settlement with Robert
Booth Jr., both the surgeon and the U.S. Attorney's Office said
the government investigation had nothing to do with the quality
of knee and hip replacements and other surgeries performed.
At issue were billings for surgeries performed between
January 1, 1995 and June 30, 1997, at Pennsylvania Hospital.
The government claimed that Booth had billed Medicare for
treatment handled by junior physicians he was training.
Endoscopy Procedures



To bill Medicare for endoscopic procedures (excluding
endoscopic surgery that follows the surgery policy),
the teaching physician must be present during the
entire viewing.
The entire viewing starts at the time of insertion of the
endoscope and ends at the time of removal of the
endoscope.
Viewing of the entire procedure through a monitor in
another room does not meet the teaching physician
presence requirement.
Anesthesia




Pay an unreduced fee schedule payment if a teaching
anesthesiologist is involved in a single procedure with
one resident.
The teaching physician must document in the medical
records that he or she was present during all critical (or
key) portions of the procedure.
The teaching physician's physical presence during only
the preoperative or post-operative visits with the
beneficiary is not sufficient to receive Medicare
payment.
If an anesthesiologist is involved in concurrent
procedures with more than one resident or with a
resident and a nonphysician anesthetist, pay for the
anesthesiologist's services as medical direction.
Interpretation of Diagnostic Radiology
and Other Diagnostic Tests




Medicare pays for the interpretation of diagnostic
radiology and other diagnostic tests 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 or she is indicating that he or she
personally performed the interpretation.
If a resident prepares and signs the interpretation,
the teaching physician must indicate that he or 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.
Psychiatry



The general teaching physician policy applies to
psychiatric services.
For certain psychiatric services, the requirement for the
presence of the teaching physician during the service
may be met by concurrent observation of the service
through the use of a one-way mirror or video equipment.
• Audio-only equipment does not satisfy to the
physical presence requirement. In the case of
time-based services, such as individual medical
psychotherapy, see subsection 8 below.
Further, the teaching physician supervising the resident
must be a physician, i.e., the Medicare teaching
physician policy does not apply to psychologists who
supervise psychiatry residents in approved GME
programs.
Time-Based Codes

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, pay for a code that specifically describes a
service of from 20 to 30 minutes only if the teaching
physician is 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: Critical Care, Psychotherapy
Interested in Learning More?
Oct 25 Evaluation and Management Coding
This class will cover how to select the proper code levels for office visits, consultations,
hospital care and more. 11:30-1 Coles 109
Nov 1
Basics of CPT Coding for Physician Practices
This is a hands-on beginning level course teaching how to use the CPT manual.
Participants will be expected to bring a CPT manual with them to class. Especially
recommended for billing personnel, office managers, etc. 11:30-1pm Coles 101
Nov 8 Modifers-Your Key to Proper Reimbursement
This class will cover CPT modifiers and their use. Class appropriate for all specialties, but
especially recommended for surgical practices 11:30- 1 Coles 109
Nov 15th
Basic ICD-9 Coding for Physician Practices
This is a hands-on beginning level course teaching how to use the ICD-9 Diagnosis
Coding Manual. Participants will be expected to bring an ICD-9 manual with them to class.
Especially recommended for billing personnel, office managers, etc. 10:30-12 Coles 109
Nov 22nd Billing for Non-Physician Practitioners
In this seminar you will learn about Medicare's requirements when billing “Incident-to” or
“under the doctor’s provider number”; provide the Medicare requirements for billing
Medicare directly under a Non-Physician Practitioner's provider number, examine which
services can be provided to Medicare patients by nonphysician practitioners; discuss
difficulties with Incident-to billing to managed care companies. 10:30-12 Coles 101