April 2004 Bulletin

Medicare documentation and coding at teaching hospitals

By Terry L. Thompson, MD

Timely documentation of services provided to patients and accurate coding are always necessary to facilitate billing and reimbursement, whether in a private practice or an academic setting. Orthopaedists at teaching hospitals, however, face the additional challenge of complying with complex and evolving rules governing documentation and coding for patients in government-funded healthcare programs such as Medicare. These unique requirements are based on the fact that the teaching orthopaedic surgeon and the resident share responsibility for patient care and documentation. These rules are published in the Medicare Carriers Manual (MCM), which is available to all Medicare providers.

Since 1996, when the Office of the Inspector General (OIG) of the Department of Health and Human Services began a nationwide initiative to review compliance by academic medical centers with these rules, many teaching institutions have been audited or have conducted self-audits. Physicians and institutions that violate the rules can be assessed monetary penalties or excluded from participation in federally-funded healthcare programs.

What Medicare covers
The Medicare program reimburses teaching hospitals for costs, including salaries and other expenses, for the teaching of resident physicians who provide patient services under the supervision of teaching physicians. When the teaching physician provides patient care along with the resident service, the Medicare program allows the teaching physician to receive payment for his or her services under Part B of the Medicare program.

When the teaching physician submits a claim to the Medicare Part B program for a service he or she did not supervise or participate in with the resident, the claim is deemed a duplicate or fraudulent claim by the OIG and the U.S. Department of Justice because the federal government has already paid for the resident physician's service under the hospital's cost report submitted to the Medicare Part A program. The following is an overview of what the “Medicare Rules” entail.

Documentation and legibility
Physicians must clearly document (in legible handwriting or in a signed, dictated note) their presence and level of participation in the services provided. Medical record documentation should be completed immediately following patient services or within sufficient time to recollect the key portions of the services provided.

Evaluation and management services
For purposes of payment, teaching physician documentation of Evaluation and Management (E&M) services must make it possible to determine that the teaching physician (1) was present with the patient, (2) evaluated the patient and (3) was involved in the plan of care. The medical necessity for the service and level of E&M code should be based on both the teaching physician's note and the resident's note. Codes should be selected based on the level of service documented, such as history, exam or medical decision making.

Codes for new and established patients should be selected according to the following guidelines:

Students may document services in the medical record. However, the teaching physician may only refer to that portion of the student's documentation of the E&M service related to the review of systems and past medical, family and social history. The teaching physician may not refer to a student's documentation of physical findings or medical decision making in his or her personal note.

Consultations
The request and reason for a consultation must be documented in the patient's medical record, or in a consultation report located in the medical record. What the consultant did or reviewed in order to reach an opinion, as well as the consultant's opinion itself, must be documented in the progress notes of the medical record, or in a consultation report located in the medical record. A written opinion or recommendation must be provided to the requesting physician.

Surgical services
“Physical presence” is one of the basics for surgical procedure documentation. The surgeon must provide documentation of his/her personal involvement and presence during critical portions of the surgical procedure. If the teaching surgeon was present throughout the entire procedure, a personal notation of “key portions” by the teaching surgeon is not required; however, if the operative report is dictated by a resident, it should be noted that the teaching surgeon was present for the entire procedure.

If the teaching surgeon is not present for the entire procedure, then the teaching surgeon must: (1) be immediately available throughout the entire operation and/or designate another physician to be immediately available; and (2) personally document the key portion(s) of the procedure for which he/she was present. The presence or level of involvement by the teaching surgeon may be noted in the record by the teaching physician, resident or operating room nurse. The teaching surgeon's signature is required on operative notes.

Medicare does not pay for the services of assistants at surgery furnished in a teaching hospital that has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available to perform the service unless certain requirements are met.

“Unbundling” is the practice of submitting bills piecemeal or in a fragmented fashion to maximize reimbursement for various procedures that are required to be billed together. Unbundling is not permitted by Medicare.

For example: During an outpatient surgical encounter, the surgeon performs an arthroscopic chondroplasty of the patient's right knee. During the same operative episode, the surgeon also uses the arthroscope to remove several loose bodies from the right knee. A separate CPT code exists for this procedure.

According to Medicare's Correct Coding Initiative (CCI) Version 9.3, the removal of loose bodies is considered a component of the comprehensive chondroplasty and should not be reported separately. In this situation, only the CPT code for the chondroplasty should be reported. Reporting the loose body removal in addition to the chondroplasty would be considered “unbundling.”

Teaching modifier
Medicare mandates the use of a HCPCS modifier (GC) for submission of Medicare claims when a service has been performed in part by a resident under the direction of a teaching physician. The use of this tracking modifier indicates that a resident was involved in the case and implicitly represents that the conditions for a Part B claim were satisfied. This modifier has no effect on the reimbursement received.

Resources
The AAOS has available several excellent resources to assist the surgeon in proper coding:

Terry L. Thompson, MD, is Chief of the Division of Orthopaedic Surgery at Howard University Hospital. He is an alumnus of the AAOS Leadership Fellow Program and a member of the Academic Business and Practice Management Committee.


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