The guidelines for providing services under the Physicians at Teaching Hospitals (PATH) rules are written by the Centers for Medicare and Medicaid Services (CMS). The physician billable services provided under these guidelines are reimbursed by CMS.
Services furnished in teaching settings are paid under the Medicare Physician Fee Schedule (MPFS) if the services are:
- Personally furnished by a physician who in not a resident;
- Furnished by a resident when a teaching physician is physically present during the critical and key portions of the service; or
- Furnished by residents under a Primary Care Exception within an approved Graduate Medical Education (GME) Program.
There are general documentation guidelines as well as Evaluation and Management (E&M) guidelines required by CMS for services to be paid when provided by an Intern or Resident.
There are General Documentation Guidelines with regards to:
- Dictated and transcribed notes
- Typed notes
- Hand-written notes
- Computer/EMR/HER generated notes
E&M Documentation guidelines:
- For any given encounter, the selection of the appropriate level if E&M service is determined according to the code of definitions in the American Medical Association’s Current Procedural Terminology (CPT) book and any applicable documentation guidelines.
- When the teaching physicians bill E&M services, they must personally document at least the following:
1) That they performed the service or were physically present during the critical and key portions of the service furnished by the resident; and
2) His/her participation in the management of the patient.
The combined entries into the medical record by the teaching physician and the resident must support the medical necessity of the service.
Primary Care Exception
Medicare may grant a primary care exception within an approved GME Program in which the teaching physician is paid for certain E&M services the resident performs when the teaching physician is not present. This exception applies to the following lower and mid-level E&M services:
Residency Programs most likely to qualify for the Primary Care Exception are:
- Family Practice;
- General Internal Medicine;
- Geriatric Medicine;
- Pediatrics; and
Certain conditions must be met and attested to in order to qualify for the Primary Care Exception:
- Services must be provided in a primary care center located in the outpatient department of a hospital or other ambulatory care entity in which time spent by residents in patient care activities is included in determining direct GME payments;
- Residents who furnish billable patient care without the physical presence of a teaching physician must have completed more than six (6) months of an approved residency program;
- Teaching physician must not supervise more than four (4) residents at any given time and must be immediately available to the residents;
- Teaching physician must not have any other responsibilities;
- Teaching physician must have primary medical responsibility for patients cared for by the residents;
- Ensure that the care provided is reasonable and necessary;
- Review the care provided by the resident during or immediately after each visit;
- Document the extent of his/her participation in the review and direction of the services provided to each patient