Evaluation and management (E/M) services -- For a given encounter, the selection of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Association’s CPT book and any applicable documentation guidelines.
For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:
Teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
Participation of the teaching physician in the management of the patient
The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.
The combined entries into the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service.
The teaching physician is required to document their presence and participation, but essentially does not need to re-document the content of the service if it was documented elsewhere by physicians, residents, or nurses.
Any contribution and participation of students to the performance of a billable service (other than review of systems and/or past family/social history, which are not separately billable, but taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.
Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed but may verify any student documentation of them in the medical record, rather than re-documenting this work.
A resident is an individual who participates in an approved graduate medical education (GME) program. A student is an individual who participates in an accredited education program/ medial school that is not an approved GME program. Medicare does not cover services provided by a student. A student may document a patient's PFSH and/or ROS but the teaching physician must review and corroborate the information and perform the remainder of the E&M visit in order to bill Medicare. The payment is based on work performed by the teaching physician, not the work performed by the student.
This service has been performed in part by a resident under the direction of a teaching physician.
Submit this modifier with services that were performed by a resident in a teaching facility under the direction of a teaching physician.
This service has been performed by a resident without the presence of a teaching physician under the primary care exception.
Submit this modifier with services that were performed by a resident in a teaching facility without the presence of a teaching physician. This modifier is informational and may only be submitted with procedure codes:
HCPCS codes G0402, G0438 and G0439
CPT codes 99202 through 99203, and 99211 through 99213
CPT codes 93005 and 93041
Note: The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.
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 and other outpatient visits via a primary care exception.
Additional updates apply to office and other outpatient visit codes for which total time is used for the visit level selection. For purposes of selecting the 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 a resident is performing such activities.
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