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, and fellows 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). 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
or 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.
3.2.4.1 The contractor shall verify
that services for which charges are billed meet TRICARE coverage
criteria as part of its responsibilities to make appropriate checks
of patient records, examining admission, progress, and discharge
notes.
3.2.4.2 While this is not required
on every claim, the contractor shall 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 or
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.
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.