HCFA Final Instructions -- ACEP Summary ======================================= Actual HCFA Final Instructions HCFA has just released the final instructions to Medicare carriers on payment guidelines for the services billed by a teaching physician which involve services performed by a resident. HCFA had released the final rule on this issue in December of 1995, but had delayed implementation of the rule until July 1, 1996. ACEP has been closely watching the development of the language to be included in these final carrier instructions and trying to influence the wording to be most favorable to emergency medicine. Although there are no changes in policy from the final rule, HCFA has clarified a few issues regarding the documentation and physical presence requirements. In general, Medicare will pay for physician services furnished in a teaching setting under the physician fee schedule only if the services are personally furnished by a physician who is not a resident, or the services are furnished jointly by a teaching physician and a resident or by a resident in the presence of a teaching physician. In both situations, HCFA considers that the services of the resident are payable through either the direct GME program or reasonable cost payments made by the fiscal intermediary. The final instructions provide this information on documentation and physical presence requirements of teaching physicians for Evaluation and Management (E/M) services. If a teaching physician documents his or her presence and participation in the E/M service, the level of service may be selected based on the extent of history and/or examination and/or the complexity of the medical decision making required by the patient and documented in his or her personal entry in the medical record which may include references to notes entered by the resident. In all cases, the teaching physician must personally document his/her presence and participation in the services in the medical record. This documentation may be either in writing or via a dictated note. The teaching physicians note must document their participation in the three key components of these services, history, physical, and medical decision making, as required by the documentation guidelines. If the teaching physician is repeating key elements of the service components obtained previously and documented by the resident, the teaching physician need not repeat the documentation in detail. Rather , the documentation of the teaching physician may be brief, summary comments that tie into the resident's entry and which confirm or revise the key elements defined for the emergency department as: relevant history of present illness and prior diagnostic tests; major findings of the physical examination; assessment, clinical impression, or diagnosis; and plan of care. Therefore, the documentation of the key elements above may be satisfied by the combination of entries into the medical record made by the resident and the teaching physician. This is a different interpretation of the final rule than previously discussed. Earlier HCFA comments would have allowed payment for only the level of service documented by the teaching physician personally without regard for the resident's notes. If the teaching physician is billing for a time based code such as critical care, they must be present for the period of time for which the claim is made. Do not bill for time spent by the resident in the absence of the teaching physician. When billing for surgical, high risk, or other complex procedures, the teaching physician must be physically present during all critical and key portions of the procedure and be immediately available to furnish service during the entire procedure. For procedures which take only a few minutes to complete, such as a simple suture, and involve relatively little decision making once the need for the operation is determined, the teaching physician must be present for the entire procedure in order to bill for the procedure. In order to bill for procedures performed through an endoscope, the teaching physician must be physically present during the entire viewing, including the insertion and removal of the device. Carriers are instructed to pay for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by a physician other than a resident. If the teaching physician's signature is the only one on the interpretation, the carrier is instructed to assume that they personally performed the procedure. If a resident signs the report, the teaching physician must indicate that they personally reviewed the image and the resident's interpretation and either agrees with it or edits the findings. "These final instructions are helpful to emergency physicians as well as to the Medicare carriers in interpreting the final rule on proper payment for teaching physicians", said Mr. McKenzie. "This has been an area targeted for fraud investigations recently and correct application of HCFA's rules is very important." -------------------------------- Date sent: Wed, 1 Oct 1997 23:54:00 -0400 Send reply to: "EMED-L a list for emergency medicine practitioners." From: "Woodrow Gandy, MD" Subject: HCFA Guidelines - MEDICAL DECISION-MAKING To: EMED-L@ITSSRV1.UCSF.EDU Another clarification on the new HCFA guidelines. This is in regard to medical decision-making. The 1998 documentation guidelines do not significantly change the medical decision-making part of the requirements. Although these requirements may look onerous, we have been required to meet them for some time. And, they are not as bad as they look. First, remember that HCFA released a point-scoring system in the past that gave us some additional insight into these requirements. Takent together, these information sources make it clear that: a) although the PHYSICIAN determines the extent of history and physical, the PATIENT determines the complexity of decision-making through the character of their presenting problem. b) the medical decision-making requirements refer primarily to important features of the patient's illness, not to the physicians "discussion" or differential diagnosis. Let's give an example.... A patient presents with symptoms consistent with a stroke or TIA. You would like to reach level 5 and need to be assured that the medical decision-making satisfies HCFA's requirements. To assess the decision-making, we look at three aspects: a) what extent of diagnoses and treatment options does this case present? b) what was the risk in this case? and c) how much data did the doctor have to dig through? Two of these three aspects must be at the highest level to justify level 5 complexity. If this is an "identified but undiagnosed problem requiring workup" then the first component (extent of diagnoses/treatment options) is "Extensive." That's the highest level for this component. We know the case meets this "Extensive" category by reading the documentation guidelines and referring to the previously-released point system. So, we just need one more component (2 of the 3) and we have level 5. The risk involved in this case is HIGH. This is easy because HCFA gives us a risk table and it shows that acute neurological changes (such as sensory loss) are in the high risk category. So, we have it right there. This is level 5 complexity. You don't even need to look at the amount of data. But, you would probably get it there as well because you would typically do quite a few tests in this patient. Again, there is a scoring system in regard to the data. In emergency medicine, we need meet only two of these three components. Generally, when you are going for level 4 or 5, it's a patient with a new problem (new to you). These are not patients presenting for a scheduled visit for a known problem. They have developed symptoms, we don't know the diagnosis, and we have to do diagnostic testing. If the diagnostic testing is a "workup" (i.e., several tests, possibly phone consultation) you are at the highest level ("Extensive") for range of possible diagnoses and treatment options. Now, assess the risk or quantity of data. Risk is specified in the Risk Table. For data, you may wish to use the point system HCFA released previously. Note that the documentation guidelines state that the doctor must provide a clinical impression, but they do NOT require an essay or a differential diagnosis. If you don't know the diagnosis and would be left with only symptoms to record (i.e., "Abdominal Pain") you may record an impression in the form of a "rule out" or "possible". However, these are difficult to handle for ICD9 coding, so you should also record the symptom as an impression. Medical decision-making is not the hard part of the new guidelines. We have a 4-page discussion of the medical decision-making issue that I would be happy to provide to anyone who would like it. ----------------------------