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Emergency Department Coding & Reimbursement Alert

Reader Question:
Know the Rules With Teaching Physicians, Residents

Question: Can our residents and teaching physicians report procedures that allow "supervision of key components?" I ask this because we were recently told that they must remain at the bedside the entire time in order to bill for the procedure. For many procedures, this isn't a problem, but watching a resident repair 15cm laceration for an hour isn't practical in a busy ED. Do the ED doctors have to remain at the bedside the whole time, or just for "key components?"

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Answer: Medicare will typically pay for physician E/M services furnished in a teaching setting under the Physician Fee Schedule only if the services are furnished by a resident seeing a patient in the "physical presence" of a teaching physician who documents his or her presence during the performance of the critical or key portions of the service and participation in the management of the patient. However, Medicare leaves it up to the attending physician to determine what the "key portions" of the service are.

Alternatively, the teaching physician and the resident may be seeing the patient at different times during a visit, provided the teaching physician independently performs the critical or key portions of the service.

For minor surgical procedures (lasting less than five minutes), the teaching physician must be physically present during the entire service. For major procedures (lasting more than five minutes), the teaching physician must be physically present during the "key portion(s)" of the service and must be immediately available to furnish service during the entire procedure. The teaching physician must document the extent of his/her participation.

For those procedures where they are not physically present for the entire service, the teaching physician must be immediately available to assist as needed. Be sure the chart documentation supports the teaching physicians' actual involvement in the case and the other documentation requirements are met before reporting the service.


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