BREAKING DOWN TEACHING PHYSICIANS AND RESIDENTS

December 13, 2023

Graduate Medical Education (GME) is a formal, hospital-sponsored or hospital-based, training program for individuals who have completed medical school and earned an MD/DO degree. This includes residency, internship, fellowship, specialty and subspecialty programs. These facilities are known as teaching hospitals.

Medicare pays for services furnished in a teaching setting through the Medicare Physician Fee Schedule (PFS) if the services meet one of these criteria:

  • They are personally furnished by a physician who is not a resident
  • They are furnished by a resident when a teaching physician (TP) is physically present during the critical or key portions of the service
  • They are furnished by a resident under a primary care exception within an approved GME program

A resident is someone who has graduated from medical school and is completing a post-graduate training program. An attending physician is a board-certified physician who has completed their residency training. Residents are supervised by attending physicians.

Requirements for billing these services:

  • Follow Evaluation and Management (E/M) documentation guidelines
  • Documentation must provide the providers presence, identify the resident(s) aiding in patient care and services. ==
  • Modifier GC should be appended to each service in the claim. Modifier GC indicates that the service was rendered with a resident under the direction of a teaching physician

Attestation examples:

  • “I was present with the resident during the visit. I discussed the case with the resident and agree with the note as documented by the resident.”
  • “I have seen and evaluated the patient. I agree with the resident’s note except [TP adds appropriate information].”

 

Primary Care Exception

Under the primary care exception, certain teaching hospital primary care centers can bill under the teaching physicians when services are provided by residents independently without teaching physicians present.

Requirements for billing these services:

  • The teaching physicians must review the care
  • Medical Decision Making (MDM) must be used to select the level of E/M visit, time cannot be used
  • Levels 4–5 office or outpatient E/M visits are not included
  • Modifier GE should be appended. Modifier GE indicates that the service was performed by a resident without the presence of a teaching physician under the primary care exception

 

 

Excite Health Partners an ECLAT Health Solutions Company

 

 

Sources:

CMS MLN006347-Teaching Physicians, Interns & Residents Guidelines

(42 CFR 415.174)