Practice Management

Academic Institutions

Hospitalists work in many types of facilities, including academic centers that utilize residents (including interns) in healthcare delivery. Medical and surgical services furnished by a resident within the scope of the training program are covered as provider services and paid by Medicare through direct Graduate Medical Education (GME) and Indirect Medical Education (IME) payments; the services of the resident may not be billed or paid for using the Medicare Physician Fee Schedule.

Similarly, the teaching physician is not paid for the resident’s work. The teaching physician is paid for their participation in patient care. In other words, payment is provided to the teaching physician for services that are:

  • Furnished by a physician who is not a resident; or
  • Furnished by a resident with a teaching physician physically present during the critical or key portion(s) of the service.

Teaching physicians participate in evaluation and management (E/M) services with residents in several ways. Consider the following teaching physician scenarios:

Using Medicare-approved linkage statements will ensure compliance with teaching physician rules.

Scenario 1: “Stand-Alone” Service

The resident sees a patient in the morning. The teaching physician independently sees the patient later that same day, performing all required elements to support their own bill (e.g. 99233: subsequent hospital care, per day, which requires at least two of these three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making). When documenting, the teaching physician can write their own note with or without any of the residents’ information. The attending note “stands alone” in support of the reported visit level. Alternatively, the teaching physician might “link to” the resident note, instead of personally redocumenting the entire service.

Appropriate documentation includes teaching physician notation of the provided critical or key portion(s) of the service and the involvement in patient management. The visit level is based upon the combined documentation, both teaching physician and resident.

Definitions for teaching-physician services

  • Resident: An individual who participates in an approved GME program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary (FI). A staff or faculty appointment, or participating in a fellowship, does not by itself alter the status of “resident.” Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full-time equivalency count of residents.
  • Student: An individual who participates in an accredited educational program that is not an approved GME program. A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student.
  • Teaching physician: A physician (other than a resident) who involves residents in the care of his or her patients.
  • Direct medical and surgical services: Services to individual beneficiaries that are either personally furnished by a physician or furnished by a resident under the supervision of a physician in a teaching hospital. All payments for such services are made by the FI for the hospital.
  • Teaching setting: Any provider, hospital-based provider, or nonprovider setting in which Medicare payment for the services of residents is made by the FI under the direct GME payment methodology, or freestanding skilled nursing facility or home health agency in which such payments are made on a reasonable cost basis.
  • Critical or key portion: The part(s) of a service that the teaching physician determines critical or key. In most cases, the terms are interchangeable. —CP

Using Medicare-approved linkage statements will ensure compliance with teaching physician rules. Examples:

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