3.1 Definitions
3.1.1 Approved
Teaching Programs
For purposes of this section,
an approved teaching program is a program of graduate medical education
which has been duly approved in its respective specialty or subspecialty
by the Accreditation Council for Graduate Medical Education (ACGME)
of the American Medical Association (AMA), by the Committee on Hospitals
of the Bureau of Professional Education of the American Osteopathic
Association (AOA), by the Council on Dental Education of the American
Dental Association (ADA), or by the Council on Podiatry Education
of the American Podiatry Association (APA).
3.1.2 Teaching
Hospital
A teaching hospital is any hospital
with physicians in training on its staff.
3.1.3 Attending
Physician
The physician who has the primary
responsibility for the medical diagnosis and treatment of the patient.
A consultant or an assistant surgeon, for example, would not be
an attending physician. Under very extraordinary circumstances,
because of the presence of complex, serious, and multiple, but unrelated,
medical conditions, a patient may have more than one attending physician
concurrently rendering medical treatment during a single period
of time. An attending physician also may be a teaching physician.
3.1.4 Teaching
Physician
A teaching physician is any physician
whose duties include providing medical training to physicians in
training within a hospital or other institutional provider setting.
3.1.5 Physician
In Training
The terms “interns and residents”
include physicians participating in approved postgraduate training
programs and physicians who are not in approved programs but who
are authorized to practice only in a hospital or other institutional
provider setting, e.g., individuals with temporary or restricted
licenses, or unlicensed graduates of foreign medical schools. There
is no change in a senior resident’s basic status for reimbursement
when the senior resident has a staff or faculty appointment or is
designated, for example, a “fellow, assistant attending surgeon,
or associate physician”. For purposes of this section, residents,
interns, fellows, etc., are treated identically and are referred
to as physicians in training.
3.1.6 Supervision
As
required for teaching physicians, supervision of physicians in training
means that the teaching physician is not required to be physically
present at all times, but must be on the provider’s premises and
available to provide immediate and personal assistance and direction
if needed. “Personal” means in person and not by telephone or other
means.
3.2 Reimbursement Of Teaching
Physicians
3.2.1 General
Teaching physicians may be reimbursed on an
allowable charge basis only when they provide services as an attending
physician or when they provide distinct, identifiable, personal
services (e.g., services rendered as a consultant, assistant surgeon,
etc.). Attending physician services may include both direct patient
care services or direct supervision of care provided by a physician
in training. Other services performed by a teaching physician such
as administration, research, and teaching cannot be reimbursed separately
on an allowable charge basis. Rather, these services are included
in the payments made to the hospital or other institutional provider
for the inpatient care.
3.2.2
Requirements
That Must Be Met To Be Considered The Attending Physician
In order to be considered an attending physician,
a teaching physician must, as demonstrated by performance of the
activities listed below, render sufficient personal and identifiable medical
services to the beneficiary to exercise full, personal control over
the management of the case. The attending physician’s services to
the patient must be of the same character, in terms of the responsibilities
to the patient that are assumed and fulfilled, as the services rendered
to other paying patients. In order to be considered an attending
physician, the teaching physician must:
3.2.2.1 Review
the patient’s history and the record of examinations and tests in
the institution, and make frequent reviews of the patient’s progress;
and
3.2.2.2 Personally examine the patient; and
3.2.2.3 Confirm
or revise the diagnosis and determine the course of treatment to
be followed; and
3.2.2.4 Either
perform the physician’s services required by the patient or supervise
the treatment so as to assure that appropriate services are provided
by physicians in training and that the care meets a proper quality
level; and
3.2.2.5 Be present and ready to perform any service
performed by an attending physician in a nonteaching setting when
a major surgical procedure or a complex or dangerous medical procedure
is performed; and
3.2.2.6 Be personally
responsible for the patient’s care, at least throughout the period
of hospitalization.
3.2.3
Direct
Supervision By An Attending Physician Of Care Provided By Physicians
In Training
3.2.3.1 Payment on the basis of allowable charges may
be made for the professional services rendered to a beneficiary
by the attending physician when the attending physician provides
personal and identifiable direction to physicians in training who
are participating in the care of the patient. While it is not necessary
that the attending physician be personally present for all services,
the attending physician must be on the provider’s premises and available
to provide immediate personal assistance and direction if needed.
Accordingly, a physician who merely reviews a patient’s progress
on a daily basis but is unavailable when a physician in training
renders care cannot be considered to be an attending physician.
The attending physician would be considered unavailable either because
he/she is not on the provider’s premises or because the activities
preclude immediate and personal assistance. On the other hand, in
the case of major surgical procedures and other complex and dangerous procedures
or situations, such personal direction must include supervision
in person by the attending physician.
3.2.3.2 The responsibilities
of a supervisory attending physician are demonstrated by such actions as:
• Reviewing
the patient’s history and physical examination; and
• Personally examining
the patient within a reasonable period after admission; and
• Confirming or revising
the diagnosis; and
• Determining the
course of treatment to be followed; and
• Assuring that any
supervision needed by the physicians in training was furnished;
and
• Making
frequent review of the patient’s progress.
3.2.4 Individual,
Personal Services
A teaching physician may
be reimbursed on an allowable charge basis for any individual, identifiable
service rendered to a beneficiary, so long as the service is a covered
service and is normally reimbursed separately, and so long as the
patient’s records contain entries personally made by the physician
which substantiate the service. The contractor is expected as part
of its responsibilities to make appropriate checks of patient records,
examining admission, progress, and discharge notes to verify that
services for which charges are billed meet TRICARE coverage criteria.
While this is not expected on every claim, the contractor should
do so on a periodic sampling basis so that the contractor becomes
familiar with the practices of the providers in its jurisdiction.
3.2.5 Documentation
Required To Reimburse Teaching Physicians On An Allowable Charge Basis
3.2.5.1 For services
as attending physician (for direct patient care or for supervision
of physicians in training). As evidence that a covered service was
rendered by the teaching physician, the patient’s medical record
must contain notes and orders which are either written, countersigned,
or initialed by the teaching physician. The notes and orders must
confirm that the teaching physician met the requirements of
paragraphs 3.2.2 and
3.2.3.
3.2.5.2 For individual,
personal services. The patient’s medical record must contain notes
and orders which confirm that the services were rendered by the
teaching physician.
3.2.6 Who May Bill
The services of a teaching physician generally
must be billed by the hospital or other institutional provider.
3.2.6.1 The hospital
or other institutional provider must bill for teaching physicians’
services when the physician is employed by or under contract to
the provider or a related entity. If the services are those of an
attending physician, as opposed to individual, personal services
rendered by the teaching physician, the conditions for qualifying
as an attending physician must have been met, and the claim must
be signed by an individual (e.g., the department head) authorized
by the physician and who is knowledgeable of the physician’s responsibilities
for being considered an attending physician.
3.2.6.2 Exception.
When the teaching physician has no relationship with the hospital
or other institutional provider (except for standard physician privileges
to admit patients) and generally treats patients on a fee for service
basis in the private sector, such teaching physicians may submit
claims under his/her own provider number (e.g., employee identification
number or Social Security Number (SSN)). Unless a teaching physician
meets this exception, the claim must be submitted by the hospital or
other institutional provider. Physicians who are employed by, or
have a contract with, the hospital or other institutional provider,
or are employed by a related entity (e.g., physicians employed by
a medical school which owns, operates or is affiliated with a hospital
or other institutional provider) are examples of teaching physicians
whose claims must be submitted by the hospital or other institutional
provider.
3.2.6.3 Billing services. Teaching physicians who are
entitled to bill independently may still contract or arrange with
another entity to submit their claims, provided the claims are submitted
under the teaching physician’s provider number. Such entities include:
any association of teaching physicians organized for the purpose
of billing for and distributing insurance monies and other payments received
for professional services to patients; and medical schools, if the
services are performed by an authorized individual provider who
is a faculty member of a medical, osteopathic, podiatric, or dental school.
3.2.7 When Teaching
Physician Services Cannot Be Reimbursed On An Allowable Charge Basis
There are situations in which a patient receives
medical services in the teaching setting for which payment on the
basis of allowable charges is not applicable. Whether or not a physician
makes a charge for services to patients which involve the participation
of physicians in training, the hospital or other institutional provider
receives reimbursement on inpatient claims for an appropriate share
of the compensation it pays its physicians in training and teaching
physicians for services in the teaching program which do not constitute
services to patients. If the teaching program is an approved program, reimbursement
for other costs of educational programs conducted by the hospital
or other institutional provider will also be available as a part
of the inpatient reimbursement made to the provider. The following
examples are common situations for which a teaching physician cannot
be reimbursed on an allowable charge basis:
3.2.7.1 The services
of a teaching physician while visiting patients during grand rounds
are basically teaching and do not contribute to an attending relationship
with any of the patients visited.
3.2.7.2 A physician
who is assigned to a teaching ward may not be routinely considered
as the attending physician for all patients in the ward.
3.3 Reimbursement
Of Physicians In Training
3.3.1 Physicians in training in
an approved teaching program, are considered to be “students” and
may not be reimbursed directly for services rendered to a beneficiary
when their services are provided as part of their employment (either
salaried or contractual) by a hospital or other institutional provider.
They should not be identified as the attending physician, they are
not authorized to execute various certifications, and separate charges
for their services should not be billed. Their services are reimbursed
to the hospital or other institutional provider through the DRG-based
payments or through payments based on billed charges, etc.
3.3.2 Services
of physicians in training may be reimbursed on an allowable charge
basis only if:
3.3.2.1 The physician in training is fully licensed
to practice medicine by the state in which the services are performed,
and
3.3.2.2 The services are rendered outside the scope
and requirements of the approved training program to which the physician
in training is assigned.