Written by Nicole Benson, Audit Manager, BA, CPC, CPMA, COSC
There are some subtle, yet important differences when teaching physicians are supervising residents in a critical care setting. Generally, for the service to be payable under the Medicare PFS, the attending physician must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service. Not only is this key for purposes of teaching supervision, but also in getting reimbursed based on CMS’s documentation guidelines.
Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care. Time spent teaching may not be counted towards critical care time “even if at bedside” per Noridian (https://med.noridianmedicare.com/documents/10542/2840524/Critical+Care+Billing+and+Coding+Presentation). ONLY time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted when reporting a time-based service such as critical care.
A combination of the teaching physician’s documentation and the resident’s documentation may support critical care services, but all requirements for critical care services must be met. The teaching physician may refer to the resident’s documentation for specific patient history, physical findings and medical assessment.
https://www.aapc.com/blog/40078-teaching-physician-guidelines-the-struggle-is-real/
Yet, the teaching physician documentation must provide substantive information, including:
- Time the teaching physician spent providing critical care
- That the patient was critically ill during the time the teaching physician saw the patient
- What made the patient critically ill
- The nature of the treatment and management provided by the teaching physician
https://www.acep.org/Clinical---Practice-Management/Teaching-Physician-Guidelines-FAQ/#sm.00000igzmjmie2eyizdfefm120q0a
Here is an example statement, “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan. Due to marked liability of the patient's pressure, rate and rhythm and the repeated need to assess and adjust medications with the resident, I was required in constant one-on-one attendance with this critically ill patient for a total duration of 45 minutes with the resident.” Remember, critical care is time directly spent with and available to the critically ill patient in the presence or absence of the resident, has a minimum of 30 minutes separate from any procedures performed, and supports medical necessity.