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.