Medicare Teaching Physician Billing Rules

Subject: Medicare Teaching Physician Billing Rules

Policy Number: FIN0303

Effective Date: February 1, 2009

Last Revised: January 13, 2009; July 12, 2012

Purpose

The intent of this document is to ensure compliance with Medicare Teaching Physician Rules by clarifying how these rules apply to the School of Dentistry. While this document outlines supervisory standards that apply in various situations based on Medicare requirements, it is recognized that the attending dentist has ultimate responsibility for the care of the patient in all settings regardless of treatment or payer.

Scope

This policy applies to School of Dentistry patient care provided all or in part by dental students or residents and billed to Medicare or Medicare Advantage Plans (Part C). Companies offering Medicare Advantage plans must follow rules set by Medicare. Services provided at University of Washington Medical Center and Harborview Medical Center are subject to the UWMC and HMC Dental Supervision Policy.

Definitions

Teaching dentist—means any dentist (other than another resident) who involves predoctoral students, post-doctoral students, or residents in the care of his or her patients. ‰

Pre-doctoral students—are students training for a DDS or DMD degree ‰

Post-doctoral students—are students with a DMD, DDS degree, or foreign equivalent. ‰

Residents—are post-doctoral students who participate in an approved graduate medical education (GME) program or dentists who are not in an approved GME program but are only authorized to practice in the hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the Fiscal Intermediary. ‰

Documentation—means notes recorded in the patient’s dental/medical records by a resident and/or teaching dentist or others in specific situations (see below) regarding the service furnished. Documentation may be dictated and transcribed, typed, handwritten or computer-generated. Documentation must be dated and include a legible signature or identity. Pursuant to Code of Federal Regulations 42 CFR 415.172(b), documentation must identify, at a minimum, the services furnished, the participation of the teaching dentist in providing the service, and whether the teaching dentist was physically present. ‰

Physically present—means the teaching dentist is 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 – means that part (or parts) of a service that the teaching dentist determines is (are) a critical or key portion(s).

Policy

1) Commitment to Compliance

a) The School of Dentistry has an active teaching program and clinical practice. The School is committed to complying with applicable State and Federal laws related to dental practice.

2) Medicare Dental Coverage

a) Medicare excludes from coverage all items and services in connection with the care, treatment, filling, removal, or replacement of teeth. This general exclusion is subject to the following exceptions:

i) If an otherwise non-covered dental procedure or service is performed by a dentist as an integral part of a covered procedure or service performed by him/her, the total service performed by the dentist is covered;

ii) A dentist who is a doctor of dental surgery or dental medicine, acting within the scope of his/her license, and who performs an otherwise Medicare-covered service (e.g., dental examination before certain surgical procedures, treatment of oral infections, and interpretation of diagnostic x-ray examinations in connection with a covered service);

iii) The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease; AND

iv) Oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery.

3) Medicare Supervision Rules a) Medicare has detailed rules governing the supervision of students, residents and fellows, and when an attending physician may bill for services provided all or in part by those individuals. The School is committed to complying with these rules.

4) Medicare Supervision Rules Applicability to Dentistry

a) Medicare supervision rules only apply to the limited universe of procedures covered by Medicare or Medicare Advantage Plans in the dental setting. A teaching dentist may only bill Medicare or Medicare Advantage Plans for services when in compliance with the Medicare Teaching Physician Supervision Rules outlined in the sections below.

b) A teaching dentist may bill Medicare or Medicare Advantage Plans a professional fee when:

i) The service is personally rendered by the teaching dentist; OR

ii) A teaching dentist is physically present during the key or critical portions of a service performed by a resident.

5) Supervision Standards for Payers Other than Medicare or Medicare Advantage Plans

a) Third party payer contracts typically do not have language describing specific supervision requirements.

b) To the extent that a third party payer contract describes supervision requirements, those requirements must be followed.

6) Documentation Requirements for Billing Evaluation and Management (E/M) Services Performed All or In Part by Residents

a) For purposes of payment, teaching dentists must document at least the following:

i) Statement that they performed the service or were physically present during the key and critical portions of the service when performed by the resident.

ii) Their participation in the management of the patient.

iii) Statement of concurrence with the findings and plan in the resident’s notes.

iv) Correction of any additional missing or inaccurate elements in the resident’s notes.

b) Combined entries into the patient record by the teaching physician and resident constitute the documentation for the service and together must support medical necessity.

c) 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 dentist.

d) The selection of appropriate E/M level will be determined by the documentation in the medical record using the American Medical Association’s Current Procedural Terminology (CPT) definitions, and any applicable documentation guidelines.

Examples of Acceptable Teaching Dentist Presence Statements

• “I saw the patient with the resident and agree with the resident’s findings and plan.”

• “I saw and evaluated the patient. Agree with resident’s note but patient has headache in addition to facial pain.”

• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans as written.”

7) Documentation Requirements for Billing Evaluation and Management (E/M) Services Involving Pre-doctoral or Post-doctoral Students

a) Any contribution by a pre-doctoral or post-doctoral student to the performance of a billable service (other than review of systems and/or past medical/family/social history) must be performed in the physical presence of a teaching dentist or resident in a service that meets teaching dentist billing requirements.

b) Pre-doctoral or post-doctoral students may document in the medical record, but the teaching dentist can only refer to student documentation of review of systems and/or past medical/ family/social history.

c) The teaching dentist may not refer to a student’s documentation of the history of present illness, physical exam findings or medical decision making in her/her personal note.

d) If the pre-doctoral or post-doctoral student documents E/M services, the teaching dentist must verify and re-document the history of the present illness as well as perform and re-document the physical exam and medical decision making activities of the service.

8) Documentation Requirements for Billing Surgical Procedures Performed All or In Part by Residents

a) When a resident is involved and the Teaching Dentist is present for or performs the surgery, the Teaching Dentist must personally document his/her physical presence or participation in the surgery.

b) In order to bill for surgical procedures, the teaching dentist must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.

c) The teaching dentist is responsible for pre-operative, operative, and post-operative care of the patient.

d) The teaching dentist determines which post-operative visits are considered key or critical and require his/her presence.

e) During non-critical portions of the procedure, the teaching dentist must be immediately available to return to the procedure, i.e., he/she cannot be performing another procedure. If circumstances prevent this level of availability, the teaching dentist must arrange for another qualified dentist to be immediately available to assist if needed.

f) For two overlapping surgeries, the teaching dentist must personally document in the patient record that he/she was physically present during the critical and key portions of both procedures. When the teaching dentist is not present during non-critical or non-key portions of the procedure and is participating in another procedure, he/she must arrange for another qualified teaching dentist to immediately assist the resident in the other case should the need arise.

g) For minor procedures that take 5 minutes or less to complete (e.g., simple suture), the teaching dentist must be present for the entire procedure.

Examples of Acceptable Teaching Dentist Presence Statements

• “I was present for the entire procedure”

• “I was present for the key portions and immediately available for the remainder of the procedure.”

• “I was present for the key portions and Dr. Beirne was immediately available for the remainder of the procedure.”

9) Documentation Requirements for Billing Diagnostic Radiology and Other Diagnostic Tests perform all or in part by Residents

a) Medicare pays for the interpretation if it is performed by or reviewed with a teaching dentist.

b) If the teaching dentist’s signature is the only signature on the interpretation, Medicare assumes that he/she is indicating that he/she personally performed the interpretation.

c) If a resident prepares and signs the interpretation, the teaching dentist must indicate that he/she has personally reviewed the image(s) and the resident’s interpretation and either agrees with it or edits the findings.

d) Medicare does not pay for an interpretation if the teaching dentist only countersigns the resident’s interpretation.

10) Documentation Requirements for Billing Time-Based Codes

a) The teaching dentist must be present for the period of time for which the claim is made for all procedure codes determined on the basis of time.

b) Example: A code that specifically describes a service of 20 – 30 minutes may only be made if the teaching dentist or is present for 20 – 30 minutes. Time spent by the resident in the absence of the teaching dentist may not be added.

c) Examples of codes in the time-based category include (but are not limited to):

i) Individual medical psychotherapy (codes 90804 -90829)

ii) Evaluation and Management (E/M) codes in which counseling dominates (>50%) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service

References

  • Medicare Claims Processing Manual • Chapter 12, Section 100 Teaching Physician Services
  • CMS Guidelines for Teaching Physicians, Interns, and Residents July 2008
  • Medicare Benefit Policy Manual
  • Chapter 16, Section 140 Dental Services Exclusion Medicare Benefit Policy Manual
  • Chapter 15, Section 150 Dental Services
  • www.medicare.gov

Dean of UW SOD:

Jean Garber, Assistant Dean, Finance & Administration

January 14, 2009