November 27, 2020 | By Grant Huang, CPC, CPMA
Auditing evaluation and management (E/M) services furnished by resident physicians under the Medicare Primary Exception (PCE) already required a firm grasp of attestation and coding rules – but now COVID-19 throws another wrench into the works. In this audit tip, we will review the rules of the Medicare PCE and examine how various regulatory waivers that are in effect during the COVID-19 Public Health Emergency affect those rules.
The Medicare PCE allows resident physicians to see patients on their own and perform a complete E/M service without supervision by teaching physicians. Prior to the public health emergency, the PCE applied in “limited situations when the resident is the primary caregiver and the faculty physician sees the patient only in a consultative role … in such programs, it is beneficial for the resident to see patients without supervision to learn medical decision making.”
The PCE allows residents to bill outpatient/office visit codes up to a maximum of level 3 (new and established patients). The PCE also allows residents to bill for a Welcome to Medicare visit (G0402) and Medicare Annual Wellness Visits (G0438, G0439). For the PCE to apply, three rules had to be met:
- The services were furnished in a primary care center located in the outpatient department of a hospital or another ambulatory care entity where the time spent by residents in patient care activities is included in determining DGME payments to a teaching hospital. This requirement is not met when the resident is assigned to a physician’s office away from the primary care center or when he or she makes home visits. The non-hospital entity should verify with the MAC that it meets the requirements of a written agreement between the hospital and the entity.
- Residents who furnish billable patient care without your physical presence have completed more than 6 months of an approved residency program.
- The teaching physician must not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability.
Furthermore, the teaching physician overseeing the residents must meet the following requirements:
- Have no other responsibilities, including the supervision of other personnel, at the time services are furnished by residents.
- Have primary medical responsibility for patients cared for by residents.
- Ensure that the care furnished is reasonable and necessary.
- Review the care furnished by residents during, or immediately after, each visit. This must include a review of the patient’s medical history and diagnosis, the resident’s findings on physical examination, and the treatment plan (for example, record of tests and therapies).
- Document the extent of their participation in the review and direction of the services furnished to each patient.
The latter two items for teaching physicians (review of residents’ care after each visit, document their participation in review and direction of services furnished) are usually satisfied via an attestation statement on each note to which the PCE applies. The attestation may have the same structure but differs from patient to patient depending on the comments the teaching physician has on each distinct encounter.
Impact of COVID-19 waivers
There are two key changes to the above rules that CMS is making via regulatory waiver, to last for the duration of the public health emergency:
- No limit on E/M code level. The cap on E/M level is eliminated, with CMS saying that “residents furnishing services at primary care centers may furnish an expanded set of services to beneficiaries, including levels 4-5 of an office/outpatient evaluation and management visit, telephone E/M, care management, and communication technology-based services.” Note that, as this excerpted statement says, the PCE expands to cover telephone E/M codes (99441-99443) and other services.
- “Virtual” review is permitted. Supervision already did not apply to resident services furnished under the PCE, but the COVID-19 waiver now allows teaching physicians to “meet the requirement to review a visit furnished by a resident remotely using audio/video real time communications technology during the PHE,” CMS states. “This flexibility can be helpful in the event that the teaching physician is not available to be present with the resident due to quarantine or social distancing.” This does mean that any attestation statement used should be amended to indicate the review was performed remotely using real-time audio/video communications.
It’s crucial for residents who are currently seeing patients under the PCE to understand that they are eligible to bill for level 4 and 5 services. This could significantly increase reimbursement, together with the expanded list of PCE-eligible services. Finally, for teaching physicians, the waiver allows them to conduct a review off-site, which could make it much easier to find an available teaching physician to perform the required review.