CMS Pub. 100-04, ch. 12, § 100.1.1

A. General Documentation Requirements

Evaluation and Management (E/M) Services -- For a given encounter, the selection of

the appropriate level of E/M service should be determined according to the code

definitions in the American Medical Association’s Current Procedural Terminology

(CPT) book and any applicable documentation guidelines.

For purposes of payment, E/M services billed by teaching physicians require that

the medical records must demonstrate:

• That the teaching physician performed the service or was physically

present during the key or critical portions of the service when

performed by the resident; and

• The participation of the teaching physician in the management of the patient.

The presence of the teaching physician during E/M services may be demonstrated by the

notes in the medical records made by physicians, residents, or nurses.

B. E/M Service Documentation Provided By Students

Any contribution and participation of students to the performance of a billable

service (other than the review of systems and/or past family/social history which are

not separately billable, but are taken as part of an E/M service) must be performed in

the physical presence of a teaching physician or physical presence of a resident in a

service meeting the requirements set forth in this section for teaching physician

billing.

Students may document services in the medical record. However, the teaching

physician must verify in the medical record all student documentation or findings,

including history, physical exam and/or medical decision making. The teaching

physician must personally perform (or re-perform) the physical exam and medical

decision making activities of the E/M service being billed, but may verify any student

documentation of them in the medical record, rather than re-documenting this work.

C. Exception for E/M Services Furnished in Certain Primary Care Centers

Teaching physicians providing E/M services with a GME program granted a primary

care exception may bill Medicare for lower and mid-level E/M services provided by

residents. Effective January 1, 2022, teaching physicians may use only medical

decision making (MDM) for purposes of E/M visit level selection when billing the

Medicare program under the physician fee schedule for office/outpatient E/M visits

under this primary care exception. For the E/M codes listed below, teaching physicians

may submit claims for services furnished by residents in the absence of a teaching

physician:

New Patient Established Patient

99201 99211

99202 99212

99203 99213

Effective January 1, 2005, the following code is included under the primary care

exception: HCPCS code G0402 (Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first 12 months of Medicare

enrollment).

Effective January 1, 2011, the following codes are included under the primary care

exception: HCPCS codes G0438 (Annual wellness visit, including personal

preventive plan service, first visit) and G0439 (Annual wellness visit, including

personal preventive plan service, subsequent visit).

If a service other than those listed above needs to be furnished, then the general

teaching physician policy set forth in §100.1 applies. For this exception to apply, a

center must attest in writing that all the following conditions are met for a particular

residency program. Prior approval is not necessary, but centers exercising the primary

care exception must maintain records demonstrating that they qualify for the

exception.

The services must be furnished in a center located in the outpatient department of a

hospital or another ambulatory care entity in which the time spent by residents in

patient care activities is included in determining direct GME payments to a teaching

hospital by the hospital’s A/B MAC (A). This requirement is not met when the

resident is assigned to a physician’s office away from the center or makes home

visits. In the case of a nonhospital entity, verify with the A/B MAC (A) that the entity

meets the requirements of a written agreement between the hospital and the entity set

forth at 42 CFR 413.78(e)(3)(ii).

Under this exception, residents providing the billable patient care service without

the physical presence of a teaching physician must have completed at least 6

months of a GME approved residency program. Centers must maintain information

under the provisions at 42 CFR 413.79(a)(6).

Teaching physicians submitting claims under this exception may not supervise more

than four residents at any given time and must direct the care from such proximity as to

constitute immediate availability. Teaching physicians may include residents with less

than 6 months in a GME approved residency program in the mix of four residents

under the teaching physician’s supervision. However, the teaching physician must be

physically present for the critical or key portions of services furnished by the residents

with less than 6 months in a GME approved residency program. That is, the primary

care exception does not apply in the case of residents with less than 6 months in a

GME approved residency program.

Teaching physicians submitting claims under this exception must:

• Not have other responsibilities (including the supervision of other personnel)

at the time the service was provided by the residents;

• Have the primary medical responsibility for patients cared for by the residents;

• Ensure that the care provided was reasonable and necessary;

• Review the care provided by the residents during or immediately after each

visit. This must include a review of the patient’s medical history, the resident’s

findings on physical examination, the patient’s diagnosis, and treatment plan

(i.e., record of tests and therapies); and

Patients under this exception should consider the center to be their primary location

for health care services. The residents must be expected to generally provide care to

the same group of established patients during their residency training. The types of

services furnished by residents under this exception include:

• Acute care for undifferentiated problems or chronic care for ongoing

conditions including chronic mental illness;

• Coordination of care furnished by other physicians and providers; and,

• Comprehensive care not limited by organ system or diagnosis.

Residency programs most likely qualifying for this exception include family practice,

general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology.

Certain GME programs in psychiatry may qualify in special situations such as when

the program furnishes comprehensive care for chronically mentally ill patients. These

would be centers in which the range of services the residents are trained to furnish, and

actually do furnish, include comprehensive medical care as well as psychiatric care.

For example, antibiotics are being prescribed as well as psychotropic drugs.

The patient medical record must document the extent of the teaching physician’s

participation in the review and direction of the services furnished to each beneficiary.

The extent of the teaching physician’s participation may be demonstrated by the notes

in the medical records made by physicians, residents, or nurses.