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Understanding Primary Care Exception

The CMS defines Primary Care Exception as ‘An exception within an approved GME Program that applies to limited situations where the resident is the primary caregiver and the faculty physician sees the patient only in a consultative role (that is, those residency programs with requirements that are incompatible with a physical presence requirement). In such programs, it’s beneficial for the resident to see patients without supervision to learn medical decision making.’

In the primary care setting, it’s possible to report low to mid-range E/M services performed by a resident without direct teaching physician supervision. However, this doesn’t mean that the teaching physician is uninvolved. Since the service is reported under the teaching physician’s name, he still has to ensure the services rendered are appropriate and medically necessary. However, when done correctly, this exception to the teaching rule could translate to more patients treated than in a typical residency program and also a better learning experience for those residents. There isn’t an application process or preapproval in order to start operating under the primary care exception. However, a primary care center must attest in writing that all of the following conditions are met.

Primary Care Exception Attestation Checklist:

·  The services were furnished in a primary care center located in the outpatient department of a hospital or another ambulatory care entity in which the time spent by residents in patient care activities is included in determining direct Graduate Medical Education (DGME) payments to a teaching hospital. Typically, the residency programs that are likely to qualify for this exception are a family practice, general internal medicine, geriatric medicine, pediatrics and obstetrics/gynecology. Certain GME programs in psychiatry may qualify in cases where the program furnishes comprehensive care to the chronically mentally ill psychiatric patient (e.g., antibiotics are prescribed along with psychotropic medication management).

· The primary care center is considered the patient’s primary location for healthcare services.

· Residents providing billable patient care without direct supervision must have completed at least 6 months of an approved residency program.

·  The teaching physician (under whom the billing is reported) cannot supervise more than 4 residents at a time and must direct the care from such proximity as to constitute immediate availability.

The supervising provider must:

· 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 your participation in the review and direction of the services furnished to each patient.

Billing and Coding of Outpatient E/M Services

As a result, the highest level of service a resident can bill for outpatient E/M services is a 3 (99201-99203 and 99211-99213). Additionally, in recent years, CMS added the Initial Preventive Physical Examination, or IPPE (G0402), and both initial (G0438) and subsequent Annual Wellness Visits, or AWV (G0439), services to the list of allowed codes under PCE. Documentation for the IPPE and AWV services are very different from a “sick” visit billed with new or established patient visit codes, so be sure your providers know the requirements of both.

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Primary Exception Rule-Important Qualifying Details to Consider

·  This is a Medicare concept, though some payers will follow Medicare’s lead. It’s important to exercise prudence by discovering which of your payers will allow this exception.

·  Residents with less than 6 months in an approved GME program are not eligible. Teaching physicians would have to be physically present for the key or critical portions of the services (see the CMS Claims Processing Manual, Chapter 12, Section 100 for detailed teaching physician guidelines).

Documentations

The teaching physician must document the extent of his or her participation in the review and direction of the services furnished to each patient. Documentation to support the services of the teaching physician may be dictated and typed, hand-written, or computer-generated.

Attach Modifiers GC and GE, as Needed

Modifier GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception must be appended to services billed under the primary care exception. By contrast, when a resident is involved with care but that care does not meet the primary care exception, the teaching physician appends modifier GC This service has been performed in part by a resident under the direction of a teaching physician to the procedure codes.

Primary Exception Rule is an exception within an approved GME Program that applies to some situations where a resident can act as the primary caregiver. While there isn’t an application process, the primary care center must attest in writing that all of a number of conditions are met. Residents will usually perform services in the medical decision making low-risk categories like a stable chronic illness. It’s crucial to remember that the service is reported under the teaching physician’s name, so he/she still has to ensure that the services rendered were appropriate and medically necessary. The benefit to this exception is that the rule could translate to more patients treated than in a typical residency program and it’s also a better learning experience for those residents regarding medical decision making.

 

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FAQs for "Medical Billing for Primary Care Exception"

Q1: What is the Primary Care Exception Rule? The Primary Care Exception Rule allows teaching physicians to bill for services provided by residents without being physically present during the exam, under specific conditions. This helps streamline billing processes in primary care settings.

Q2: How does the Primary Care Exception Rule benefit primary care practices? It enables faster and more efficient billing and coding by reducing the need for teaching physicians to be present for every patient encounter. This can lead to more streamlined operations and better use of physician time.

Q3: What are the requirements for billing under the Primary Care Exception Rule? Practices must meet specific criteria, including the residency program’s focus on primary care, the types of services provided, and the supervision level of residents. Detailed documentation is required to ensure compliance.

Q4: How can primary care billing and coding errors be minimized? Ensure accurate documentation, stay updated on coding changes, and regularly train staff. Utilizing experienced medical billers and coders can significantly reduce errors and improve the efficiency of your billing processes.

Q5: How do medical billers and coders help with primary care billing? Medical billers and coders assist by managing claims, verifying patient information, ensuring accurate coding, and staying current with billing regulations. This helps reduce errors, claim denials, and administrative burdens, allowing physicians to focus on patient care.

Q6: What common challenges are faced in primary care billing and coding? Common challenges include coding errors, insufficient documentation, incorrect patient information, and staying updated with changing regulations. Addressing these challenges is essential for effective revenue cycle management.

Q7: How can primary care practices stay updated on billing and coding changes? Regular training, subscribing to industry updates, and working with professional medical billing and coding services can help practices stay current with changes in billing and coding regulations.

Q8: Why is accurate coding important in primary care billing? Accurate coding ensures that claims are processed correctly, leading to timely reimbursements and reducing the likelihood of claim denials or audits.


Published By - Medical Billers and Coders
Published Date - Aug-16-2019 Back

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