Medicare’s expanded compliance rules
Are you a ’teaching physican’?
But residents never sign my reports....
Nuances for reporting the GC modifier
Nuances for reporting an attestation
Key definitions and added nuances
Teaching physicians are subject to two Medicare compliance rules that
don’t plague their nonteaching brethren. In particular, they must (1)
append a unique "teaching physician" modifier to their CPT procedure codes
on claims to Medicare, and (2) literally attest in each and every medical
report to having met the program’s teaching physician compliance rules.
Several nuances affect compliance, and they’re not universally well understood.
For example, what level of "active involvement" by a resident makes the
senior medical doctor a "teaching physician" in Medicare’s eyes? When
does a "fellow" count as a "resident" instead of a "physician" in this
context? What’s the "critical portion" of a fine needle aspiration, a
bone marrow biopsy, a transfusion medicine service, or a microscopic tissue
exam that must be supervised by a senior pathologist to bill a professional
fee? If residents don’t sign your final reports, can you ignore Medicare’s
teaching physician rules altogether?
This article explains the basic compliance parameters that control claim
filing and medical reporting by pathologists who train residents as an
integral part of their daily patient care duties. It focuses on the key
compliance nuances that tend to trip up practitioners or cause them to
be exposed to greater audit risk than is generally acceptable. Specific
suggestions and examples are provided so you can quickly and effectively
plug the holes, if any, in your internal policies and practices.
Medicare’s expanded compliance rules
In general, patient care services by interns, residents, and fellows
that fall within the scope of their training program are covered by Medicare
as hospital Part A services, not as separately billable physician Part
B services.1 However, the Medicare carrier
will pay a separate charge to a "teaching physician," if he or she is
"physically present" to supervise the "critical portion" of the patient
care service by an intern, resident, or fellow. Medicare’s teaching physician
rules stipulate when the program does and doesn’t pay a physician’s charge
for resident-performed patient care services, in addition to the amount
that’s payable to a hospital.
The fundamental teaching physician rules are set forth in section 415
of the Code of Federal Regulations (Part 42). In general, they provide
that, if a resident participates in or performs a patient care service
in a teaching hospital, Medicare Part B physician fee schedule payment
is made "if [a] teaching physician is present during the key portion of
[the patient care] service or procedure for which payment is sought,"
but only if that presence is documented in the patient’s medical record.2
Radiologists, pathologists, and other physicians who interpret diagnostic
tests receive special mention—but not special treatment per se—in
the regulations. Part B payment is permitted "for the interpretation of
diagnostic radiology and other diagnostic tests [like tissue exams] if
the interpretation is performed or reviewed by a physician other than
a resident."3 However, the patient’s
medical record (for example, a pathology report) "must indicate that the
physician personally performed the interpretation or reviewed the resident’s
interpretation with the resident."4
The Centers for Medicare and Medicaid Services, the federal agency that
administers the Medicare program, directly or through its predecessor
agency, the Health Care Financing Administration, has interpreted the
regulations to impose two compliance obligations on teaching physicians
that don’t apply to other practitioners. In particular, according to CMS,
a teaching physician must:
- Add a special modifier to his or her CPT/HCPCS codes. Section
4113(A) of the Medicare Carriers Manual directs teaching physicians
to report procedure code modifier GC with any medical service that involves
a resident as an active participant.5
By using the modifier, the teaching physician certifies that he or she
was "present during the key portion of the service, and [was] immediately
available during the other parts of the service." This requirement has
been in place since Jan. 1, 1997.
- Attest to being physically present for the service. CMS in
§15016(A) of the Medicare Carriers Manual defines "documentation"
for a teaching physician’s services to include a notation in the patient’s
record regarding "the service furnished, the participation of the teaching
physician in providing the service, and whether the teaching physician
was physically present [to supervise the resident]." There’s an arguably
conflicting sentence in §15016(C)(5) that appears at first glance
to provide an "out" for radiologists, pathologists, and other physicians
who interpret diagnostic tests. It basically says that if a resident
doesn’t sign the interpretive report, Medicare assumes the senior physician
personally performed the interpretation alone. This misleading sentence
will be fully discussed and the ambiguity resolved in a moment.
There’s no question the GC modifier and the medical report attestation
requirements are highly redundant. Nevertheless, when the facts warrant,
you must fulfill both rules to be in compliance; simply adhering to one
isn’t sufficient. Look at it this way: Medicare’s auditors have two chances
to "get" you, but you’ve got only one chance to "get it right."
Are you a ’teaching physician’?
Knowing whether you’re a "teaching physician" in Medicare’s eyes is crucial,
because the extra compliance rules apply only if you are. The mere fact
that a resident is present when you examine slides doesn’t necessarily
make you a "teaching physician," even if you impart wisdom to the resident
as you diagnose specimens. Of course, it’s conceivable that you’re a "teaching
physician" for some medical services, but not all.
Basically, Medicare says you’re a teaching physician if you "involve"
residents in the medical services you render. The policy guidance from
CMS, taken as a whole, suggests the involvement must be ongoing, active,
and significant before the extended compliance rules apply. Looked at
from the opposite angle, if residents usually involve themselves in your
patient care work only in a passive way (more as observer than participant),
Medicare doesn’t see you as a teaching physician. Two examples will help
clarify the distinction.
- Teaching setting. Residents actively participate in the
care and treatment of patients in most accredited teaching hospitals.
In pathology, they microscopically examine slides for the surgical and
cytology cases they’ve been assigned, and then they record their diagnostic
impression for each case. The electronic or paper trail bears the signature
or initials of the resident who’s developed the tentative diagnosis.
The senior pathologist (teaching physician) later microscopically examines
the slides in the presence of the resident, they discuss the case, and
then the senior pathologist signs the diagnosis as his or her own, or
modifies it before sending the electronic or manual paperwork to transcription
for the final report.
This scenario is precisely what Medicare has in mind when it defines
a teaching physician and talks about such a physician being "physically
present" during the "key portion" of a medical procedure. Residents are
enrolled in an accredited graduate medical education (GME) teaching program,
and the services are conducted in an acknowledged teaching hospital under
the direction and supervision of a physician who holds an appointment
to the faculty of an academic medical department. Residents are involved
in patient cases ongoing, and they participate in an active, significant
way; for example, in pathology they proactively examine slides and formally
record their interpretive judgment, which becomes part of the patient’s
medical record upon acceptance or change by the senior physician.
In a situation like this, Medicare expects the procedure code on the
CMS-1500 claim for the teaching physician’s medical service to incorporate
the GC modifier to disclose that a resident was actively involved in the
service. In addition, the medical report for the case must include an
attestation by the teaching physician concisely explaining his or her
role in the service vis-à-vis that of the resident.
- Nonteaching setting. Community hospitals sometimes affiliate
with teaching medical centers, and in so doing, they invite residents
to gain real-world experience by learning alongside members of the medical
staff. However, the education provided in these settings isn’t hands-on
(that is, it’s not "learning by doing") as it is in the teaching centers.
Instead, the residents learn by observing the work of senior physicians
and by listening as seniors explain what they’re doing, why they’re
doing it, etc. A pathology resident might preview slides and make personal
notes about the likely diagnosis, but the senior pathologist doesn’t
really consider the resident’s thoughts when formulating his or her
diagnosis for the case.
This is not a "teaching physician" situation, at least insofar as Medicare
is concerned. While residents may receive academic credit for the time
spent at the community hospital, the hospital itself doesn’t have an accredited
teaching program. Similarly, while the senior physicians who work with
residents may very well be competent educators in their own right, they’re
not full-fledged faculty of a university or medical college.
Even more telling, the senior physicians, when working with residents,
don’t change their fundamental approach to patient care compared with
the times they’re not working with residents. For example, when diagnosing
a specimen, the pathologist doesn’t consciously or regularly consider
what a resident may have to say, except as may be necessary to answer
a question. Also, the paperwork (electronic and otherwise) for the case
won’t show a resident’s "footprint" in a way that suggests he or she "actively
participated" in the patient’s care; a resident won’t be mentioned anywhere
in the medical report for the case because he or she was merely an incidental
observer of the work of the senior pathologist.
In a situation like this, Medicare doesn’t view the pathologist as a
"teaching physician," so the GC modifier and medical report attestation
requirements don’t apply.
Of course, life often doesn’t present such clear-cut fact situations
as these. You and your attorney will want to consider Medicare’s full
formal guidance before reaching a final decision on your compliance obligation
as a teaching physician or group of such physicians. This is especially
important considering the aforementioned ambiguous guidance aimed directly
at pathologists and radiologists. Let’s now look carefully at that controversy.
But residents never sign my reports....
Ironically, the Medicare compliance instruction that comes closest to
being unique to teaching pathologists is also the one that gives health
law attorneys and physician consultants fits over CMS’ intentions, and
the corresponding practical implications. The instruction comes from §15016(C)(5)
of the Medicare Carriers Manual and is directed specifically to the "interpretation
of diagnostic radiology and other diagnostic tests" and procedures. It
states: "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."6
The importance of this sentence to academic departments of pathology
accrues from the fact that most of them accommodate only the senior pathologist’s
signature in medical reports; seldom does a resident’s name (or initials
even) appear in the final report. Notwithstanding, logs, worksheets, internal
consult and order forms, and other documents preparatory to the final
report clearly bear the initials or signature of a resident. So here’s
the conundrum: When does a diagnosis become an "interpretation" for Medicare
purposes—at the time the resident makes the diagnosis for confirmation
by the senior pathologist, or at the time it’s transcribed to the final
The most aggressive reading of this ambiguous sentence concludes that
CMS policy waives application of federal law and regulation in relation
to teaching pathologists who don’t disclose the identity of a resident
in the final medical report. Proponents argue that neither the GC modifier
nor the attestation requirement applies in this instance; in essence,
they postulate that the content of one’s final medical report determines
his or her status as a teaching physician, not the overall context, process,
or provable facts. Conventional wisdom rejects this viewpoint, because
it fundamentally runs contrary to the spirit and intent of the teaching
physician provisions of the law, and, simply put, it’s "too good to be
A less aggressive take on the elusive meaning of the subject sentence
is that it relieves pathologists, radiologists, and other "interpreting
physicians" of an administrative burden (that is, the attestation), but
doesn’t change anything so far as the GC modifier is concerned. In other
words, this view holds that CMS offers these physicians a shortcut attestation
method: Don’t mention a resident in your final report, and your signature
alone will then be accepted as proof of your compliance with the "present
during the critical portion of the service" rule. If true, this prescription
means teaching pathologists don’t have to include a formal attestation
in their final reports, but they still have to append the GC modifier
to procedure codes on their claims.
Conventional wisdom holds that, while the second viewpoint is far less
radical than the first, it still doesn’t "feel right" in the context of
the overall teaching physician compliance objectives and instructions.
For example, why would CMS put so much faith and trust in the signature
of a radiologist or pathologist, but not so other physicians? Also, how
would an auditor know that a pathologist wasn’t merely signing a resident’s
interpretation, without actually looking through a microscope? And last,
when CMS talks about the teaching physician’s signature being "the only
signature on the interpretation," it may have more than just the final
report in mind; for example, it may also be thinking about all the worksheets
and internal forms that bear the signature or initials of a resident.
The sensible—albeit conservative—understanding of CMS’ intentions
regarding this key but ambiguous sentence picks up where the last stated
concern leaves off: It assumes CMS is referring to the totality of the
case record, not just the final report. (This is consistent with the approach
used by CMS with surgeons, internists, and the like, when it takes into
account "the combined entries" of residents and senior physicians to "constitute
the [entire] documentation for the service.")7
Following this logic, if all paperwork for a case shows that the teaching
physician performed the patient service with no or only passive involvement
by a resident, then his or her signature on the final report is all that’s
needed; it’s not necessary to include an attestation in the report, nor
is it appropriate to append the GC modifier to the procedure code(s).
Conversely, if the preparatory paperwork for a case shows that a resident
played an active role in developing the interpretation that was reviewed
and accepted or modified by the senior pathologist, the final report must
include an appropriate attestation and the GC modifier must be affixed
to the procedure code(s), even though the resident isn’t identified anywhere
in the final report itself. The College of American Pathologists appears
to share this understanding of CMS’ equivocal language.8
You and your attorney need to carefully weigh the arguments and the limited
evidence in support of the competing theories for whether an attestation
is or isn’t required when residents aren’t named in pathology reports.
When deliberating, also take three important practical considerations
into account: (1) in matters of government policy, what at first blush
looks like a loophole in reality is often a noose; (2) auditors know which
hospitals have resident education programs, and they’re always on the
lookout for claims that don’t match that environment; and (3) the capabilities
of most lab reporting systems today are such that template attestations
can be added to reports with relative ease at virtually no cost.
Nuances for reporting the GC modifier
Medicare requires modifier GC with CPT and HCPCS procedure codes to
declare that a resident actively participated in the service, but that
the senior physician in whose name the service is billed was "present
during the key portion of the service, and [was] immediately available
during the other parts of the service."9
If a resident wasn’t involved in the service, or was involved only in
a passive way (for example, merely as an observer), you don’t need to
report the GC modifier on the senior physician’s claim.
The GC modifier is appended to the applicable CPT or HCPCS procedure
code in addition to any other modifier(s) that may apply. For example,
teaching pathologists very frequently report modifiers 26 (professional
component only) and GC together (for example, 8830526GC).
Accuracy and reliability of modifier reporting are enhanced the more
the billing office and its computer are involved. This also minimizes
the burden on physicians and residents. When setting up the GC modifier
capture and reporting system, you need to take three distinct fact situations
- For procedures that always involve residents in an active way under
the direct supervision of a senior physician, it’s best to let the billing
computer automatically add the GC modifier to the procedure code, when
the account is for a Medicare beneficiary.
- The GC modifier shouldn’t be appended to the procedure code of services
that never involve the active participation of a resident. A policy
of reporting the GC modifier with all codes billed—knowing that
residents have nothing to do with some—undermines your credibility.
- A mechanism to selectively add the GC modifier to the procedure code
of each service that has no set pattern of active participation by residents
must be established. There are very few procedures that fall into this
category in most teaching settings, so it’s quite reasonable to ask
teaching physicians to assume responsibility for adding the GC modifier
to the procedure code they report to the billing office in these instances.
For example, when a teaching physician performs a fine needle aspiration
without imaging guidance by him- or herself, procedure code 10021 is
ticked off on the charge ticket; when that service is performed by a
resident under the direction of a teaching physician, procedure code
10021GC is checked instead. Again, selective reporting of the GC modifier
in these situations is critical to your compliance and credibility with
In many jurisdictions, Medicare is the only payer that instructs teaching
physicians to report the GC modifier when the circumstances warrant. Check
with your state Medicaid agency and the managed care plans and private
insurers with which you do business to see if they want you to use the
GC (or some other) modifier when filing claims for services to their beneficiaries
or insured persons.
Nuances for reporting an attestation
The second requirement teaching physicians must attend to when billing
Medicare for services involving the active participation of residents
is the attestation of compliance. The patient’s medical record (report)
must provide clear evidence that the teaching physician was physically
present to personally supervise the resident during the critical portion
of the medical procedure for which the teaching physician seeks payment.
CMS doesn’t offer or prescribe specific attestation language for teaching
physicians such as pathologists and radiologists who conduct their work
primarily by a visualization technique. (That is, the physicians don’t
commonly have physical contact with the patient. Their diagnosis is made
by review and interpretation of a radiographic film, a stained tissue
slide or smear, or an EKG strip that’s representative of some part of
the patient’s body.) However, CMS is quite specific regarding the objective
of the attestation: It’s to "indicate that [the teaching physician] personally
reviewed the image [, slide, smear, etc.] and the resident’s interpretation
and either [agreed] with [or edited] the findings."10
CMS also makes clear that merely countersigning the resident’s interpretation—without
looking at the radiographic image, stained slide, smear, or whatever—isn’t
a teaching physician function that’s payable from Medicare Part B trust
The attestation language you develop for your medical reports should
be concise and to the point. The information you want to convey depends
in large part on the procedure under review. For example, for tissue slides
and cytology smears, the main idea to get across is that the teaching
pathologist personally examined the material and made or confirmed the
reported diagnosis. Alternatively, when dealing with bone marrow biopsies,
you want to confirm that the teaching physician personally directed the
procedure as the resident performed it.
Following are several sample attestations adapted from the reports of
client physicians. Attestations should appear in the main body of the
final report, in obvious proximity to the signature or initials of the
senior pathologist who supervised the major service that’s the subject
of a particular attestation. Only one attestation is needed for all like-kind
procedures covered by a medical report; for example, one statement will
nicely handle multiple specimens for H&E light microscopy (with or without
special stains as well), but a separate statement should be provided for
your intraoperative consultation on frozen sections.
- Surgical pathology, final diagnosis: "As the senior physician, I
attest that I: (i) examined the relevant preparation(s) for the specimen(s);
and (ii) rendered or confirmed the diagnosis(es)."
- Surgical pathology, intraoperative consult: "I, the senior physician,
attest that I: (i) examined the relevant preparation(s) for the specimen(s)
while in the surgical suite or frozen section room; and (ii) rendered
or confirmed the diagnosis(es)."
- Fine needle and other nongynecological cytology final diagnosis: "I,
the senior physician, attest that I: (i) examined the described preparation(s)
for the specimen(s); and (ii) rendered or confirmed the diagnosis(es)."
- Fine needle aspirate immediate study: "As the senior physician, I
attest that I: (i) attended the fine needle procedure; (ii) immediately
examined smears while the procedure was underway; and (iii) determined
or confirmed the adequacy of the specimen(s)."
- Fine needle aspiration: "I, the senior physician, attest that I: (i)
attended the fine needle aspiration procedure; (ii) directed and supervised
the procedure; and (iii) was immediately available to further assist
the resident/fellow before and after the procedure."
- Bone marrow aspiration and/ or biopsy: "As the senior physician, I
attest that I: (i) attended the bone marrow aspiration and/or biopsy
procedure(s); (ii) directed and supervised the procedure(s); and (iii)
was immediately available to further assist the resident/fellow before
and after the procedure(s)."
- Clinical pathology test interpretation: "As the senior physician,
I attest that I: (i) examined the relevant preparation(s) and/or image
for the specimen(s); and (ii) rendered or confirmed the interpretation(s)."
- Transfusion medicine/blood bank service: "I, the senior physician,
attest that I: (i) reviewed patient clinical records if indicated; (ii)
reviewed relevant lab test results; and (iii) rendered or confirmed
the interpretation/treatment recommendation."
Specialty labs such as electron microscopy, flow cytometry, and cytogenetics
should develop teaching physician attestations that uniquely characterize
their internal process. The preceding samples will nonetheless serve as
patterns; for example, the attestation statement for an electron microscopy
lab very likely will be nearly identical to that shown for surgical pathology
(final diagnosis). Note, however, that a unique attestation for any particular
specialty lab is necessary only if: (1) residents or fellows actually
participate in a material way in the diagnosis of cases within the specialty
lab; and (2) the senior physician who interprets and reports results for
the specialty lab is different than the senior physician who’s assigned
to a particular case overall. The need for specialty lab specific attestation
language commonly comes up only in very large operations that have a significant
volume to justify a dedicated physician per specialty lab.
As earlier mentioned, you’ll regularly encounter situations where two
or more attestations should appear in one medical report. For example,
a renal pathology report might contain three different attestations. One
would cover the work of renal pathologist No. 1 who, together with a resident,
examined the biopsy under a grossing scope and rendered an intraoperative
finding of "sufficient glomeruli"; the attestation would be of type "surgical
pathology, intraoperative consult" displayed in the preceding list, and
it would appear in the intraoperative consultation section of the medical
report. One would cover the work of renal pathologist No. 2 who, together
with a resident or fellow, examined the H&E light microscopy permanent
section slides, the histologic special stains, and the immunofluorescence
stains; the attestation would be of type "surgical pathology, final diagnosis"
displayed in the preceding list, and would appear immediately below the
second pathologist’s electronic signature. The third attestation would
cover the work of the electron microscopy specialist (a physician) who,
together with a resident, examined and reported on the ultra-thin sections;
the attestation would be similar or identical to type "surgical pathology,
final diagnosis" in the list, and it would appear immediately below the
specialist’s electronic signature in the addendum or standalone report,
whichever approach is used at that particular institution.
Another instance when as many as three different attestations might well
appear in one medical report occurs with fine needle aspiration cases.
Even though the same cytopathologist might supervise the three distinct
case services—that is, fine needle aspiration, immediate assessment
of specimen adequacy, and interpretation of the permanent smears—by
a resident or fellow, the services are sufficiently unique from a place,
time, and process perspective that individualized attestations are encouraged.
The attestation for each major service should be juxtaposed to the senior
physician’s signature or initials in the three distinct sections of the
final report—that is, the report sections that segregate the aspiration
from the rapid assessment consultation, and those two activities from
the final interpretation. Sample wording for each of the three attestations
is provided in the preceding list. You might be tempted to try to construct
one attestation covering all three major services, but that’s not encouraged,
for reasons explained next.
Some academic departments of pathology use an attestation template that
purports to cover the work of multiple physicians on one case, the work
of one physician on significantly different procedures (for example, bone
marrow biopsy versus diagnostic evaluation of the biopsy), or both. The
main problem with all-inclusive attestation templates is that either they’re
lengthy and grammatically clumsy, or they’re so general that they lack
sufficient precision. In the first instance, auditors might reasonably
question the veracity of an attestation, which looks like so much "boilerplate"
in the face of variable fact circumstances. In the second instance, auditors
may not be willing to accept all the assumptions that have to be read
into the general attestation to make it work in particular fact situations;
for example, to say that "slides were examined" doesn’t put the teaching
physician in the frozen section room. Another factor to consider when
weighing the pros and cons of multiple statements as suggested above versus
a single all-inclusive template is that, for the vast majority of cases,
only one of the several statements will be invoked anyway; for example,
more than 80 percent of surgical pathology cases don’t have an intraoperative
consultation, so the "final diagnosis" version alone will suffice.
How you go about getting the right attestation statement posted to the
right place in your medical reports under the right circumstances depends
entirely on the functionality of the medical reporting software you use.
Indeed, you may have to develop considerably different mechanisms for
surgical/cytology cases versus clinical pathology and/or transfusion medicine
cases. Most lab information systems today accommodate "macros" or "auto-text,"
or both, to greater or lesser extent, and you should make ample use of
those features to avoid repetitive typing errors, omissions, and inefficiency.
The three key things to strive for when designing your attestation reporting
mechanism are (1) positioning each attestation in such a way that there
can be no question about which teaching physician is taking responsibility
for which medical service; (2) flexibility in attestation language, as
suggested by the various samples provided earlier; and (3) credibility
As stressed when discussing the GC modifier, credibility of reporting
is important. An attestation shouldn’t be posted automatically, unless
it’s true that, for a given class of specimens, a resident or fellow is
always actively involved, under the supervision of a senior physician.
An attestation shouldn’t be posted in conjunction with a medical service
if: (1) the senior physician performed the service without a resident
being present or while a resident merely observed; or (2) a resident or
fellow performed the service, but a senior physician wasn’t present to
supervise the critical portion of the procedure. In the last instance,
Medicare Part B shouldn’t be billed.
It’s virtually impossible to know with certainty at the time medical
reports are signed and released what payer or insurer (if any) will be
billed for a particular patient’s care. Therefore, when designing your
attestation system, the best idea is to simply post an attestation(s)
to all reports that meet the resident or fellow active participation and
senior physician supervision criteria. The billing computer or office
staff will then apply the GC modifier only to claims that go to Medicare.
The fact that this protocol causes you to "over document" your medical
services to non-Medicare patients shouldn’t create an issue with anyone;
I’ve never encountered nor heard of a Medicaid agency, managed care company,
or private insurer challenging or questioning this practice.
Key definitions and added nuances
Key definitions and additional nuances that should be taken into account
when managing and monitoring your compliance with Medicare’s teaching
physician documentation and billing rules are listed here. Attention to
these matters, when considered together with the preceding information
and suggestions, will help ensure that any outside scrutiny of your billing
practices will yield a favorable conclusion.
- Resident services not supervised. Unless a teaching physician
is physically present to personally supervise the patient care services
of a resident performed under the auspices of an accredited graduate
medical education program, no party—not the teaching physician,
faculty practice plan, hospital, or resident—may bill Medicare
Part B for the services.
- Fellow as resident. A "fellow" who’s enrolled in and performing
patient care services as part of a training course offered through a
teaching hospital’s accredited graduate medical education program is
treated the same as a "resident" for purposes of applying Medicare’s
teaching physician coverage and payment rules.11
Conversely, patient care services outside a physician’s fellowship course
and those not sanctioned by a hospital’s GME program may be billed by
or in the name of the fellow (when properly signed up with Medicare),
without regard for Medicare’s teaching physician rules.
- Technical vs. professional component billing. Under usual
circumstances, a hospital can bill its Medicare Part A fiscal intermediary
for the technical component of a medical service performed by a resident
or fellow, even though a teaching physician professional charge to Part
B may not be allowed. For example, if a resident performs a bone marrow
biopsy on a Medicare beneficiary without a teaching physician being
present, the hospital can bill CPT code 38221 to the intermediary, but
nobody can bill a charge to the carrier.
- Definition of "physically present." The teaching physician
must be "physically present" to supervise a patient care service conducted
by a resident, if he or she is going to bill Medicare for it. The phrase
"physically present" in this context means "in the same room ... as
the patient [or resident, depending on the medical service]."12
Think "looking over the resident’s shoulder" (literally) as the measure
of physical proximity, because, by analogy, Medicare says viewing an
entire endoscopy procedure "through a monitor in another room does not
meet the teaching physician presence requirement."13
- Definition of "key or critical portion." The teaching physician
must supervise the "key or critical portion" (Medicare uses those adjectives
interchangeably) of a patient care service by a resident to be entitled
to bill for it. For the most part, Medicare relies on the teaching physician
to make a bona fide determination of the "key or critical portion" of
any given medical service. One exception is "minor procedures": Medicare
says the teaching physician "must be present for the entire procedure"
if it only takes a few minutes (five, for example). Another exception
is an endoscopy procedure, which requires the teaching physician’s presence
in the suite the entire time the scope is in the patient.14
- Prime examples from the world of pathology. Following are
examples of how to apply the "physically present" and "key or critical
portion" criteria to work situations commonly encountered by teaching
- When an interpretation or diagnosis is based on the microscopic examination
of slide-based material, the teaching pathologist must perform such
an exam on the material to fulfill the "key or critical portion" criterion.
This is true regardless of whether the preparation represents tissue,
a cytologic or hematologic smear, or a body fluid such as spinal fluid.
Each separately billable preparation must be separately examined by
the teaching pathologist; for example, the lung biopsy frozen section
and H&E slides, and the AFB special stain slide, must be microscopically
examined by the teaching pathologist to bill codes 88331, 88305, and
88312 for the separate procedures. The "physically present" criterion
means the teaching pathologist’s frozen section exam has to be conducted
in the frozen section room, while the operative procedure is underway.
- The teaching pathologist must personally identify the gross specimen
to bill an 88300 code for a "gross only" exam by a resident. This is
usually accomplished by having the senior physician in charge of the
grossing room on any given day walk through that area once or twice
to verify that the material in each "gross only" tissue container is
consistent with the gross description that’s been logged or dictated
by the resident.
- Medicare certainly would consider fine needle aspirations, bone marrow
biopsies, and bone marrow aspirations to be "minor procedures," or at
least more akin to the usual endoscopy procedure than to a complicated
surgery. Therefore, a teaching pathologist should attend the entire
procedure by a resident or fellow, if he or she is going to bill for
it. "Physically present" here means looking over the resident’s shoulder.
- A medical service such as an E/M (evaluation and management) consult
or therapeutic apheresis always involves face-to-face patient contact.
To bill a professional fee for such a service, the teaching pathologist
must participate in or repeat the critical portion of the service, which
must include an activity involving face-to-face time with the patient.15
- To bill a clinical pathology consultation, a transfusion medicine
or physician blood bank service, or another clinical pathology service,
the patient’s record must demonstrate that the teaching pathologist
personally reviewed relevant portions of the chart (if indicated), all
pertinent laboratory test results, or both, to confirm the medical finding
of the resident.
Teaching pathologists are subject to more stringent and extensive medical
report documentation and claim coding requirements than their nonteaching
brethren. However, by adopting the policies and practices explained in
this article, you should be able to manage the added tasks with nominal
extra time, interference with patient reporting, or incremental expense.
Adhering to these instructions and suggestions will also help minimize
your billing compliance risks.
Notes and references
- Section 415.160 of the Code of Federal Regulations (Part 42) provides
that a teaching hospital can, under certain circumstances, elect to
receive payment from its Medicare Part A fiscal intermediary for the
medical and surgical patient care services of its graduate medical education
residency teaching physicians, whether or not they’re actually employed
by the hospital. When this arrangement is in effect, there’s no billing
to the Medicare Part B carrier by anyone, so the "teaching physician"
coverage rules don’t apply. This arrangement is seldom encountered in
practice, so added attention isn’t given to it in this article.
- 42 CFR §415.172(a) and (b).
- 42 CFR §415.180(a).
- 42 CFR §415.180(b).
- Interestingly, the new Internet Only Manual system, and chapter 12
of the Medicare Claims Processing Manual (CMS IOM Pub. 100-4)
in particular, doesn’t mention the GC modifier. However, there’s been
no Change Request issued to rescind the §4113(A) instruction, the
modifier is still active in the 2005 HCPCS table per the CMS Web site,
and various other CMS documents continue to reference its use (see,
for example, the Medicare Learning Network pamphlet Teaching Physician
Services: Guidelines for Teaching Physicians and Residents, Sept.
2004, available on the CMS Web site). This appears to be another example
of a paper-based to Internet-only manual transcription snafu; see "Coping
with the errors in Medicare’s new Internet-only policy manuals" in the
March 2005 issue of CAP TODAY for more information about this controversy.
- As fate would have it, there’s no guidance in §100, chapter 12,
of the new Medicare Claims Processing Manual (or any other
Internet-only manual to my knowledge) that’s recognizable as a transcribed
or clarified version of the "interpretation of ... radiology and other
diagnostic tests" language in the Medicare Carriers Manual.
(Section 100 covers teaching physicians.) One might assume CMS intentionally
omitted anything comparable to the §15016(C)(5) verbiage to signify
that there’s really no difference among radiologists, pathologists,
and other clinicians so far as the teaching physician service documentation
requirements are concerned. Alternatively—and, arguably, more
likely—this may simply be another instance where the new guidance
falls short of the old in terms of completeness, accuracy, and helpfulness.
Either way, the void that’s opened up in Medicare’s latest policy manual
doesn’t change the fundamental compliance concern we’re grappling with
- See, for example, §15016(A)(8) and (C)(1).
- On page 38 of its November 1998 Compliance Guidelines for Pathologists,
the College advises that teaching pathologists should clearly and regularly
state "on the pathology report ... that the specimen has been examined
and the interpretation is agreed with or edited." Hence, the College
advises ongoing inclusion of attestations in final pathology reports,
even though it knows the senior physician’s signature is likely going
to be the only one on those reports.
- Medicare Carriers Manual,§4113(A).
- Medicare Carriers Manual, §15016(C)(5)
- Medicare Carriers Manual, §15016(A)(1).
- Medicare Carriers Manual, §15016(A)(9).
- Medicare Carriers Manual, §15016(C) (4)(c).
- Medicare Carriers Manual, §15016 (A)(7), 15016(C)(4)(a)(3),
and 15016(C) (4)(c).
- Medicare’s rules for covering E/M services by residents have been
relaxed a bit the past couple of years, to the point where the teaching
physician no longer has to meet face-to-face with the patient in all
instances. Notwithstanding, considering the skepticism that typically
greets a pathologist’s E/M charge on a claim to Medicare and private
insurers, it’s best that you strictly adhere to the old rules so as
not to tempt extraordinary scrutiny and possible challenge.
Dennis Padget is president of DLPadget Enterprises Inc., a pathology
business practices research and publishing firm in Simpsonville, Ky. The
advice he provides in this article is his own. The CAP makes no representation
regarding the efficacy of his advice, and no representation is implied
by the appearance of this article in CAP TODAY.