A Top-10 Federal Audit Survival Guide for Physicians at Teaching Hospitals

By Michael Calahan

Teaching hospitals and health care entities with faculty practices that host residency programs have long attempted to balance proficient, high quality resident education with operationally efficient patient load management, both of which must be achieved by following basic foundational principles of coding, documentation and compliance as well as extra layers of federal regulations aimed at teaching physicians.  Such is the predicament of the “physicians at teaching hospitals” (PATH) arena.

A perennial favorite of the OIG’s Annual Work Plan – though admittedly less scrutinized in the last few years – PATH activities are still heavily examined by a variety of other active, even vigorous federal audit initiatives.  As with other professional fee-for-service (or “pro-fee”) programs for Medicare beneficiaries, PATH services are coded/billed under the teaching physician’s name.  They are then reviewed and analyzed for appropriateness of payment and compliance by CMS via its jurisdictional Medicare Administrative Carriers (MACs) and Part B Carriers, by the Comprehensive Error Rate Testing (CERT) program, and soon at a “complex” level by the ubiquitous audit programs conducted by the Recovery Audit Contractor (RAC) entities.  Other aggressive auditing efforts such as those conducted by the Zone Program Integrity Contractors (ZPICs) are not far behind.

The key to victory under these current and impending levels of scrutiny and oversight, as always, lies in the quality of the provider’s (i.e., the teaching physician’s and the resident’s) medical record (MR) documentation.  But in terms of documented PATH criteria, what exactly are the ‘feds’ seeking to confirm and how can the typical facility not only meet these basic thresholds but excel in the current audit milieu?  Here’s a quick, at-a-glance run-down of the “Top 10” critical areas that come into focus in federal audits, as well as the data points successful teaching physician programs should add to their own internal auditing and monitoring agendas.

1. Missing or Poorly Documented E/M Key Component: History:  The “history” is the first-listed federal audit finding of import, and together with the other two key components for non-time based evaluation and management (E/M) services, namely the (1) physical exam and the (2) medical decision making, it governs E/M code selection before ever considering the PATH guidelines themselves.  The most typical finding for “history” is that is has been skipped or omitted from the MR documentation (which may be a deliberate provider decision for subsequent visits) or that the history documentation is too scanty to count it as significant in the E/M leveling process.

Survival Guide:  Even in PATH scenarios, the basic E/M guidelines must be met first; missing or lack of recorded critical elements including chief complaint (CC), past medical, family/social history (PFSH), review of systems (ROS) and history of present illness (HPI) can cause the level of service to be downcoded by auditors prior to even assessing the PATH aspects of the service.  Contradictory data between certain elements occurs frequently, e.g., the HPI reveals “Left should pain” but the CC, which is the data point anchoring the visit, states “Here for pharyngitis follow up.”  Be careful of jurisdictional idiosyncrasies such as certain Part B Carriers/MACs requiring the CC to be documented by the provider only.  Summarization terms like “noncontributory” documented for the PFSH or ROS may be viewed as inadequate … know your Part B Carrier/MAC jurisdictional preferences.

2. Authorship of MR Documentation:  Illegible teaching physician and resident signatures, unauthenticated MR contributions, as well as the third party reviewer’s inability to differentiate ancillary staff notes (e.g., made by the nurses and medical assistants) from teaching physician’s and resident’s MR documentation accounts for the numerous audit “dings” within this category of audit findings.

Survival Guide:  Legible signatures are required to certify services; illegible signatures submitted without evidence of proof-of-signature are equated to unsigned MR documentation.  Similarly, mixing ancillary staff/scribe notes in the body of the teaching physician’s and/or resident’s clinical notes without signature clarification is tantamount to “indeterminate” or unauthenticated documentation.  If the federal reviewer cannot navigate through the MR documentation without asking “who did what?” then there is a basic problem.  Ensure the teaching physicians, residents and finally the ancillary staff each sign/date all clinical note contributions so that authorship of the MR documentation is clear.  Maintain signature logs of all residents, especially in non eMR environments.

3. Proof of Teaching Physician’s Presence & Participation:  The teaching physician’s presence and participation in the resident’s services with the shared patient are only substantiated (i.e., proven) by his/her contribution to the MR documentation for the service (e.g., an inpatient hospital visit or a surgical procedure).  Brief, simplistic statements by the teaching physician such as “Discussed with resident and agree … J.Smith, MD” are inadequate to substantiate active participation in the care of the shared patient.  Documentation by the resident of the teaching physician’s presence/participation is unacceptable “proof” of the service.

Survival Guide:  It is incumbent upon the teaching physician to actively participate in the care of the shared patient with the resident, performing a face-to-face visit with the patient and communicating with/to the resident the various subjective and objective data, the assessments and impressions, as well as the medical decision making and care plan.  The teaching physician must be present for the key or critical portion(s) of the service.  Data already obtained and documented by the resident need not be re-documented by the teaching physician, but a summarizing but illustrative set of statements must be added to the patient’s MR by the teaching physician such as “I was present with the resident during the PE and MDM. I discussed the case with him/her and the patient, and concur with the findings and assessment. We discussed the care plan as documented.”  Of import, the teaching physician’s note must reference the resident’s MR documentation in order for each provider’s notes to be combined into a singular E/M level for coding and billing (for surgical notes see #8).

4. Coding Restrictions Under the Primary Care Exception:  Meeting basic E/M documentation guidelines and proving the teaching physician’s presence and participation aside, a very basic coding misunderstanding under the primary care exception (PCE) is the cause of the majority of errors in this category.  Whether due to provider misconception of the rule or coder/biller lack of understanding in terms of which codes are valid under the PCE, high level E/M services such as 99204/99205 and 99214/99215 have been reported in error.  Currently, only low to mid-level E/M codes, e.g., 99201-99203, 99211-99213 and unique HCPCS Level II code G0402 for the IPPE (“Welcome to Medicare”) physical exam, as well as G0438 and G0439 for Annual Wellness Visits, Initial and Subsequent, are authorized under the PCE.

Survival Guide:  The first step to compliance is sticking to the acceptable E/M and HCPCS-II G-codes for specific Medicare services under the PCE.  MR documentation requirements include a complete review of the resident’s notes by the teaching physician, as well as documentation of the extent of the teaching physician’s review and if germane, his/her participation in the service including any follow up discussion with the resident, being careful to note any change(s) in data points or the care plan, when these changes occur.  Because the resident acts as a de facto primary care provider under the PCE, the teaching physician must be immediately available if needed and cannot supervise more than four (4) residents under the PCE at any one time.

5.     Misapplication of PATH Modifiers -GC and -GE:  There are two basic modifiers associated with PATH services: -GC ‘This service has been performed in part by a resident under the direction of a teaching physician’ and -GE ‘This service has been performed by a resident without the presence of a teaching physician under the primary care exception.’  Problems arise when the modifiers are mis-reported, erratically reported or not reported at all.

Survival Guide:  Modifiers -GC and -GE are not reimbursement modifiers but instead are certification and tracking modifiers, attesting to the resident and teaching physician services provided (it is the teaching physician’s name under which all PATH services are billed).  They do not affect reimbursement but do alert the Carrier/MAC that specific resident/teaching physician services are being rendered.  Modifier -GC is appended to all resident services, e.g., E/M, surgery and anesthesia, but modifier -GE can only be appended to services authorized under the PCE, i.e., E/M services 99201-99203, 99211-99213, G0402, G0438 & G0439.  Some facilities have the appropriate modifier(s) hard-coded in their system, which are tripped when a resident’s e-signature is engaged for specific types of services; other facilities soft-code these modifiers, deliberately assessing the services and then hand-applying the modifiers where appropriate.

6.     Critical Care Often = Critical Errors in MR Documentation:  Residents in teaching settings can participate in critical care services.  The reporting of critical care services under CPT code 99291 Critical care, first 30-74 minutes and CPT code 99292 Critical care, each additional 30 minutes, is predicated upon “duration of time” being documented in the MR notes.  Exact minutes do not have to be documented but the total duration of time spent face-to-face in critical care with the patient must be documented.  Federal auditors often find lapses in the MR documentation in terms of time spent in critical care, as well as confusion in terms of “who did what?” because the MR notes are unclear.  Authentication (signature) issues also surface with critical care.

Survival Guide:  All of the foundational parameters for critical care reporting in accordance with CPT and CMS guidelines apply; layered atop those regulations are the teaching physician rules.  These include the fact that the teaching physician must be present during all of the critical care time reported, time spent teaching the resident (not caring for the patient) is not counted as critical care time, time spent by the resident without the teaching physician is not counted towards the final critical care calculation, and finally the teaching physician’s notes must elaborate on the nature of the critical care and underlying cause(s), the treatment and management of the patient, and a reference to the resident’s portion of the notes (i.e., a data bridge).  Both providers’ notes are combined into the final critical care documented episode.  The foundational concept for all time-based PATH services applies as well (see next numbered top-10 finding).

7.     Time-Based Coding and Reporting Errors:  As alluded to in the previous top-10 audit finding, there is a foundational concept undergirding all time-based services in the PATH arena: the teaching physician must be present for the total amount of ‘claimed time’ in order for the service to be paid at that level, e.g., a time-based service of 30 minutes is only paid if the teaching physician is present for 30 minutes.  The time involved always depends on the time spent by the teaching physician, not the resident.  Federal auditors find – due to documentation disparities in the MR notes – that the teaching physician’s presence for the ‘claimed time’ is in doubt or appears unclear.

Survival Guide:  Basic time-based concepts apply: (a) the teaching physician must be present for the entire time reported; (b) time spent teaching the resident, or by the resident alone, is not counted towards the final time calculation; (c) time spent caring for the patient by the teaching physician without the resident is, in fact, counted toward the final time calculation; and (d) time-based services must have the duration of time spent well-documented in the MR notes for the service.

8.     Poorly or Ambiguously Documented Surgical Sessions:  In the typical surgical suite in the PATH arena, teaching surgeons work with residents and might oversee a single surgical session or two overlapping sessions (three or more are not paid under PATH guidelines), as well as different kinds of surgical sessions (e.g., an endoscopic surgery session, a diagnostic endoscopy procedure, a traditional open surgery and/or a minor surgical procedure).  PATH guidelines and documentation standards are similar for all of these surgeries with one exception (see below).  Federal auditors typically find discrepancies in the documentation of the procedures, such as the teaching surgeon’s presence for the key/critical portions of the service, the teaching surgeon’s contribution to the surgical note, and/or authentication issues (e.g., a resident dictating and signing the operative report without the teaching surgeon’s contribution and signature).

Survival Guide:  While the teaching surgeon’s presence might not be needed during the opening/closing of the surgical field (as he/she so decides – not the resident), the teaching surgeon’s presence must be established in the documentation at different levels for different kinds of surgical services.  (1) For minor procedures, the teaching surgeon must be present for the entire service (even if this seems a bit unnecessary for a minor surgical service); (2) for high risk procedures usually referenced by a Local or National Coverage Determination (LCD, NCD) such as most interventional radiology procedures or cardiac catheterizations, the teaching surgeon must likewise be present for the entire service; (3) for endoscopies, e.g., colonoscopy, the teaching surgeon must be present for the entire “viewing,” which starts at insertion of the scope and ends at removal; (4) for overlapping procedures, e.g., traditional open surgery and/or endoscopic procedures (such as a laparoscopic surgical procedure, which is differentiated from a typical “viewing” endoscopy), the teaching surgeon must be present only for the pre-identified key/critical portions of the service.  In all of these aforementioned surgeries, the teaching surgeon must document their involvement/presence for each surgical session.  However, the one documentation exception is for a “single surgery.”  For single surgeries, while the teaching surgeon must still be present for the key/critical portions of the service, he/she does not have to document their presence/participation.  This is the one exception to the common PATH guideline for resident and teaching physician documentation; in this instance the resident (or the OR nurse) can fully document the service, as well as the teaching surgeon’s presence/participation, without the teaching surgeon making a contribution to the MR notes and/or operative report.  The teaching surgeon must, however, authenticate the operative report.  While this may seem counterintuitive, it is the current regulation [CMS Medicare Claims Processing Manual 100-04 Ch. 12. Section 100.1.2.A.1].  A few other miscellaneous guidelines apply to all surgical services such as oversight/supervision, availability of the surgeon or authorized proxy when assistance is needed, etc.

9.     Teaching Anesthesiologists and CRNAs – Credibility Rests on Documentation and Modifiers:  Federal auditors find inadequate MR documentation of the teaching anesthesiologist’s or teaching CRNA’s presence/participation in the billed anesthesia services as well as inconsistent or inaccurate modifier reporting.

Survival Guide:  Confusion often surrounds this area of PATH guidelines but the regulations are fairly straightforward.  As of 1-1-2010, teaching anesthesiologists can oversee one case + one resident, one case + multiple residents, or two cases + multiple residents (and another multi-case scenario involving the Medical Direction Rule).  Teaching CRNAs can oversee one case + one SRNA as well as two concurrent cases + several SRNAs.  For Medicare claims, aside from the -GC modifier signifying a PATH service, the teaching anesthesiologist appends modifier -AA to his/her services (Anesthesia services performed personally by Anesthesiologist) and the CRNA appends modifier -QZ (CRNA service:  without medical direction by a physician).  The anesthesiologist and CRNA must be available during case oversight to furnish the residents with assistance or anesthesia-related services if needed (or arrange to have a proxy, when supervising more than one case).  CRNAs must document their presence during pre-/post-anesthesia care.  Documentation for both anesthesiologists and CRNAs must reflect their presence/participation in the key/critical portions of the anesthesia services.

10.  Residents and Diagnostic Reports:  Often, federal auditors find that the residents have dictated and signed the diagnostic test, study or radiology report without any diagnostic study documentation or countersignature by the teaching physician.

Survival Guide:  All diagnostic studies (i.e., the test results or images themselves) must be reviewed by and the reports must be authenticated by the teaching physician if/when the resident also provides an interpretation.  Further, the teaching physician cannot simply countersign the study, but must offer interpretations, findings and a final authentication.  CMS only pays for “interpretation and report” when performed by a physician or qualified NPP.

 

Operational protocols understood and enacted by the teaching physicians are tantamount to success in the busy PATH arena.  As always careful, meticulous MR documentation is the cornerstone of compliance.  While the ten federal audit scenarios outlined above do not illustrate all of those arising out of the teaching physician environment, they do address the predominant findings and are a good starting point for a solid PATH program leading to better compliance and appropriate reimbursement for the teaching physician.

 

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Michael Calahan, PA, MBA, AHIMA-Approved ICD-10-CM/PCS Trainer, is the V.P. of Physician & Hospital Compliance with HealthCare Consulting Solutions (HCS).  He can be contacted at mcalahan@hcsglobal.net or mikiecal@hotmail.com questions or comments.