Teaching hospitals and healthcare entities with faculty practices that host residency programs long have attempted to balance high-quality resident education with operationally efficient patient load management, both of which must be achieved by following basic foundational principles of coding, documentation and compliance.
Extra layers of federal regulations aimed at teaching physicians now also play into this equation. Such is the predicament in the “physicians at teaching hospitals” (PATH) arena. A perennial favorite of the Office of Inspector General’s (OIG’s) Annual Work Plan, though admittedly less scrutinized during the last few years, PATH activities still are examined closely by a variety of other active, even vigorous, federal audit entities.
As with other professional fee-for-service (or “pro-fee”) programs for Medicare beneficiaries, PATH services are reviewed and analyzed for appropriateness of payment and compliance by the Centers for Medicare & Medicaid Services (CMS) via its jurisdictional Medicare Administrative Carriers (MACs) and Part B Carriers, by the Comprehensive Error Rate Testing (CERT) program, and soon at a complex level by the ubiquitous Recovery Audit Contractor (RAC) entities. Other aggressive auditing efforts, such as those conducted by the Zone Program Integrity Contractors (ZPICs), are not far behind.
The key to victory, considering these current and impending levels of scrutiny and oversight, as always lies in the quality of the provider’s (i.e., the teaching physician’s and the resident’s) medical record (MR) documentation.
But in terms of documented PATH criteria, what exactly are the feds seeking to confirm, and how can the typical facility not only meet these basic thresholds, but excel in the current audit milieu?
Here’s a quick, at-a-glance rundown of the top 10 hot spots that tend to bubble to the surface as it pertains to the federal audit risk areas for PATH services, plus a few focal points all successful healthcare entities should concentrate on as part of their own internal auditing and monitoring agendas.
1. Missing or Poorly Documented E/M Key Component: History. The “history” is the first-listed federal audit finding of import, and together with the other two key components for non-time-based evaluation and management (E/M) services, namely the a) physical exam and the b) medical decision-making, it governs E/M code selection before the PATH guidelines themselves even must be considered. The most typical negative finding for “history” is that it has been skipped or omitted from the MR documentation (which may reflect a deliberate provider decision for subsequent visits) or that the history documentation is too scant to count it as significant in the E/M leveling process.
Survival Guide: Even in PATH scenarios, basic E/M guidelines must be met first; lack of recorded critical elements such as chief complaint (CC), past medical, family/social history (PFSH), review of systems (ROS) or history of present illness (HPI) can cause the level of service to be downcoded by auditors even prior to assessing the PATH aspects of the service. Contradictory data among certain elements appears frequently (for example, when the HPI reveals “left shoulder pain” but the CC, which is the data point anchoring the visit, states “here for pharyngitis follow-up.”) Be careful of jurisdictional idiosyncrasies, such as certain Part B carriers/MACs requiring the CC to be documented by the provider only. Summarization terms like “noncontributory” documented for the PFSH or ROS also may be viewed as inadequate, so know your Part B carrier/MAC jurisdictional preferences.
2. Authorship of MR Documentation. Illegible teaching physician and resident signatures, unauthenticated MR contributions, and third-party reviewers’ inability to differentiate ancillary staff notes (such as those penned by the nurses and medical assistants) from teaching physicians’ and residents’ MR documentation all account for the numerous audit “dings” that fall within this category of audit findings.
Survival Guide: Legible signatures are required to certify services; illegible signatures submitted without evidence of proof are equated to unsigned MR documentation. Similarly, mixing ancillary staff/scribe notes in the body of the teaching physician’s and/or resident’s clinical notes without signature clarification is tantamount to “indeterminate” or unauthenticated documentation. If the federal reviewer cannot navigate through the MR documentation without asking “Who did what?” then there is a basic problem. Ensure that the teaching physicians, residents and finally the ancillary staff all sign and date all clinical note contributions so that authorship of the MR documentation is clear. Maintain signature logs of all residents, especially in non-eMR environments.
3. Proof of Teaching Physician’s Presence and Participation. The teaching physician’s presence and participation in rendering the resident’s services with a shared patient only are substantiated (i.e. proven) by his or her contribution to the MR documentation for the service (i.e. an inpatient hospital visit or a surgical procedure). Brief, simplistic statements by the teaching physician, such as “discussed with resident and agree, J. Smith, MD” are inadequate to substantiate active participation in the care of the shared patient. Documentation by the resident of the teaching physician’s presence and/or participation is unacceptable “proof” of the service.
Survival Guide: It is incumbent upon the teaching physician to participate actively in the care of a patient shared with a resident, performing a face-to-face visit with the patient and communicating with the resident regarding the various subjective and objective data, assessments and impressions, and medical decision-making and the care plan. The teaching physician must be present for the key or critical portion(s) of the service. Data already obtained and documented by the resident need not be re-documented by the teaching physician, but a summarizing, illustrative set of statements must be added to the patient’s MR by the teaching physician (such as “I was present with the resident during the PE and MDM. I discussed the case with him/her and the patient and concur with the findings and assessment. We discussed the care plan as documented.”) Of importance is that the teaching physician’s note must reference the resident’s MR documentation in order for each provider’s notes to be combined into a singular E/M level for coding and billing (for surgical notes, see No. 8).
4. Coding Restrictions Under the Primary Care Exception. Meeting basic E/M documentation guidelines and proving the teaching physician’s presence and participation aside, a very basic coding misunderstanding under the primary care exception (PCE) is the cause of the majority of errors in this category. Whether due to provider misinterpretation of the rule or coder/biller lack of understanding of which codes are valid under the PCE, high-level E/M services (such as 99204/99205 and 99214/99215) have been reported in error. Currently, only low- to mid-level E/M codes (such as 99201-99203, 99211-99213 and unique HCPCS Level II code G0402 for the IPPE), physical exam codes, as well as G0438 and G0439 for Annual Wellness Visits, Initial and Subsequent, are authorized under the PCE.
Survival Guide: The first step toward achieving compliance involves sticking to the acceptable E/M and HCPCS-II G-codes for specific Medicare services rendered under the PCE. MR documentation requirements include a complete review of the resident’s notes by the teaching physician as well as documentation of the extent of the teaching physician’s review – and, if germane, his or her participation in the service(s), including any follow-up discussion with the resident (being careful to note any changes in data points or in the care plan, when these changes occur). Because the resident acts as a de facto primary care provider under the PCE, the teaching physician must be immediately available if needed and cannot supervise more than four residents under the PCE at any one time.
5. Misapplication of PATH Modifiers -GC and GE. There are two basic modifiers associated with PATH services: -GC (“This service has been performed in part by a resident under the direction of a teaching physician”) and -GE (“This service has been performed by a resident without the presence of a teaching physician under the primary care exception.”) Problems arise when the modifiers are misreported, erratically reported or not reported at all.
Survival Guide: Modifiers -GC and -GE are not reimbursement modifiers, but certification and tracking modifiers, attributing to the resident and teaching physician services provided (it is the teaching physician’s name under which all PATH services are billed). These modifiers do not affect reimbursement, but do alert the carrier/MAC that specific resident/teaching physician services are being rendered. Modifier -GC is appended to all resident services (such as E/M, surgery and anesthesia), but modifier -GE only can be appended to services authorized under the PCE (such as E/M services 99201-99203, 99211-99213, G0402, G0438 and G0439). Some facilities have the appropriate modifier(s) hard-coded in their systems, prompted when a resident’s e-signature is required for specific types of services; other facilities soft-code these modifiers, deliberately assessing the services and then hand-applying the modifiers where appropriate.
6. Critical Care Often (Critical Errors in MR Documentation). Residents in teaching settings can participate in critical care services. The reporting of critical care services under CPT code 99291 (Critical Care, first 30-74 minutes) and CPT code 99292 (Critical care, each additional 30 minutes) is predicated upon “duration of time” being documented in the MR notes. Exact minutes do not have to be documented, but the total duration of time spent rendering face-to-face critical care to the patient must be documented. Federal auditors often find lapses in the MR documentation in terms of time spent in critical care, as well as confusion in terms of “Who did what?” because the MR notes often are unclear. Authentication (signature) issues also surface in this area.
Survival Guide: All of the foundational parameters for reporting critical care in accordance with CPT and CMS guidelines apply; layered atop those regulations are the teaching physician rules. These rules include the fact that the teaching physician must be present during all of the critical care time reported. Time spent teaching the resident (not caring for the patient) is not counted as critical care time, nor is time spent by the resident without the teaching physician. Finally, the teaching physician’s notes must elaborate on the nature of the critical care and underlying cause(s) and the treatment and management of the patient, and a reference to the resident’s portion of the notes must exist (i.e. a data bridge). Both providers’ notes are combined into the final documented episode of critical care. The foundational concept for all time-based PATH services applies as well (see the next finding).
7. Time-Based Coding and Reporting Errors. As alluded to in the previous finding, there is a foundational concept undergirding all time-based services in the PATH arena: the teaching physician must be present for the total amount of “claimed time” in order for the service to be paid at this level. In other words, a time-based service that takes 30 minutes to render only is paid if the teaching physician is present for all 30 minutes. The time involved always depends on the time spent by the teaching physician, not the resident. Due to documentation disparities in the MR notes, federal auditors often find that the teaching physician’s presence for the “claimed time” is in doubt or appears unclear.
Survival Guide: Some of the aforementioned basic time-based concepts apply here: a) the teaching physician must be present for the entire time reported; b) time spent teaching the resident, or time in which the resident is alone, is not counted toward the final time calculation; c) time spent caring for the patient by the teaching physician without the resident is, in fact, counted toward the final time calculation; and d) time-based services must have the duration of time spent well-documented in the MR notes.
8. Poorly or Ambiguously Documented Surgical Sessions. In the typical surgical suite in the PATH arena, teaching surgeons work with residents and might oversee a single surgical session or two overlapping sessions (three or more are not paid under PATH guidelines), as well as different kinds of surgical sessions (an endoscopic surgery session, a diagnostic endoscopy procedure, a traditional open surgery, a minor surgical procedure, etc.). PATH guidelines and documentation standards are similar for all of these surgeries, with one exception (see below). Federal auditors typically find discrepancies in the documentation of these procedures, such as the teaching surgeon’s presence for key/critical portions of the service, the teaching surgeon’s contribution to the surgical notes, and/or authentication issues (such as when a resident dictates and signs the operative report without obtaining the teaching surgeon’s contribution and signature).
Survival Guide: While the teaching surgeon’s presence might not be needed during the opening/closing of the surgical field (as he or she so decides, not the resident), the teaching surgeon’s presence must be established in the documentation at different levels for different kinds of surgical services. For minor procedures, the teaching surgeon must be present for the entire service (even if this seems a bit unnecessary for a minor surgical service); for high-risk procedures usually referenced by a local or national coverage determination (LCD, NCD), such as most interventional radiology procedures or cardiac catheterizations, the teaching surgeon likewise must be present for the entire service; for endoscopies, such as a colonoscopy, the teaching surgeon must be present for the entire “viewing,” which starts at insertion of the scope and ends at removal; and for overlapping procedures or traditional open surgery and/or endoscopic procedures (such as a laparoscopic surgical procedure, which is differentiated from a typical “viewing” endoscopy), the teaching surgeon must be present only for the pre-identified key/critical portions of the service. In all of these aforementioned scenarios, the teaching surgeon must document his or her involvement and presence for each surgical session. However, the one exception when it comes to documentation is for a “single surgery.” For single surgeries, while the teaching surgeon still must be present for the key/critical portions of the service, he or she does not have to document presence or participation. Again, this is the one exception to the common PATH guidelines for resident and teaching physician documentation; in this instance the resident (or the OR nurse) can document the service fully, even as it pertains to the teaching surgeon’s presence and participation, without the teaching surgeon making a contribution to the MR notes or operative report. The teaching surgeon must, however, authenticate the operative report. While this may seem counterintuitive, it is the current regulation (CMS Medicare Claims Processing Manual 100-04 Ch. 12. Section 100.1.2.A.1). A few other miscellaneous guidelines apply to all surgical services, such as oversight/supervision, availability of the surgeon or authorized proxy when assistance is needed, etc.
9. Teaching Anesthesiologists and CRNAs – Credibility Rests on Documentation and Modifiers. Federal auditors often find inadequate MR documentation of the teaching anesthesiologist’s or teaching CRNA’s presence and participation in billing for anesthesia services, as well as inconsistent or inaccurate modifier reporting.
Survival Guide: Confusion often pervades this area of PATH guidelines, but the regulations are fairly straightforward. As of Jan. 1, 2010, teaching anesthesiologists can oversee one case and one resident, one case and multiple residents, or two cases and multiple residents (there also is another multi-case scenario involving the Medical Direction Rule). Teaching CRNAs can oversee one case and one SRNA, as well as two concurrent cases and several SRNAs. For Medicare claims, aside from the -GC modifier signifying a PATH service, the teaching anesthesiologist appends modifier -AA to his or her services (“Anesthesia services performed personally by anesthesiologist”) and the CRNA appends modifier -QZ (CRNA service without medical direction by a physician). The anesthesiologist and CRNA must be available during case oversight to furnish residents with assistance or anesthesia-related services, if needed (or arrange to have a proxy when supervising more than one case). CRNAs must document their presence during pre- and post-anesthesia care. Documentation for both anesthesiologists and CRNAs must reflect their presence and participation in the key/critical portions of the anesthesia services.
11. Residents and Diagnostic Reports: Often, federal auditors find that residents have dictated and signed the diagnostic test, study or radiology report without any diagnostic study documentation contribution or countersignature by the teaching physician.
Survival Guide: All diagnostic studies (i.e., the test results or images themselves) must be reviewed by the teaching physician, who also must authenticate reports if and when the resident provides an interpretation. Furthermore, the teaching physician cannot simply countersign the study, but must offer interpretations, findings and a final authentication. CMS only pays for “interpretation and report” when it is performed by a physician or qualified NPP.
Operational protocols being understood and adhered to by the teaching physicians will translate to success in the busy PATH arena. Teaching facilities have incorporated into their hospital codes straightforward bylaws that address resident/teaching physician scenarios and the responsibilities of each person in those situations. As always, careful, meticulous MR documentation is the cornerstone of compliance. While the federal audit scenarios outlined above do not illustrate all of the scenarios arising out of the PATH environment, they do address the predominant findings and represent a good starting point for a solid PATH program, which leads to improved compliance and appropriate reimbursement for PATH services.
About the Author
Michael Calahan, PA, MBA, AHIMA-Approved ICD-10 CM/PCS Trainer, the vice president of hospital and physician compliance for HealthCare Consulting Solutions.
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