At the same time that practices concerning supervision of residents and their work hours have been under review, the Office of the Inspector General (OIG) has been increasing its scrutiny of how well physicians who supervise residents document their services when Medicare is billed. Ten years ago, the OIG initiated audits of physicians at teaching hospitals, called PATH audits. The purpose was to determine if the presence of the attending physician was documented in the patient records, and to verify that the appropriate level of service was provided.
The Stakes Are High
The first audit, which took place at the University of Pennsylvania in Philadelphia, resulted in the 1996 OIG determination that the university had received $5.9 million in overpayment from Medicare; the university voluntarily repaid “double damages” in the amount of $12 million. Based upon violations of the False Claims Act, the violator is potentially liable for triple damages. When Jefferson Medical College in Philadelphia subsequently found itself under OIG audit, the college conducted an independent review voluntarily at its own expense in the hope of limiting punitive damages, and ultimately settled for a similar amount. In four of the first six academic institutions investigated, significant errors were identified, resulting in settlements of $67 million.
The OIG continued with PATH audits, finding evidence of both compliance and overpayment based on the documentation provided. By 2000, PATH audits had recovered more than $1 billion, and annual savings to CMS were estimated at nearly $16 billion. However, the rising frequency of criminal investigations has been the most alarming trend observed, with 414 filed in 2000.
With increasing education at teaching facilities regarding how to bill Medicare appropriately for physicians’ supervisory services, it seemed that documentation was improving, until recently. A compliance officer at the University of Washington alerted the OIG to repeated failures to correct inappropriate billing patterns and inadequate documentation for services billed to Medicare. A grand jury was convened and indictments were levied upon two surgeons and a radiologist.
How to Comply
Under the current Medicare system, the Centers for Medicare and Medicaid Services (CMS) makes payments to teaching hospitals for resident physician services provided to Medicare patients through Medicare Part A. This payment includes graduate medical education costs as well as indirect medical educations costs, estimated to be $8 billion in 1998. CMS also separately pays for the services of attending physicians under Medicare Part B if the attending physician provided a properly documented service. (The CMS clarified these regulations in July 1996.)
In order for the attending physician to separately bill Medicare for a service provided at the teaching hospital, he or she must be physically present and directly participate in the key portion of the service or procedure for which reimbursement is sought. Most university hospitals have instituted compliance programs and have developed institutional policies which sometimes go further in the documentation required of their attending staff. The CMS’ compliance regulations, published in the Federal Register on Feb. 23, 1998, included the requirements that:
- only services provided could be billed;
- the attending physician was responsible for proper documentation; and
- the documentation must exist in the patient record and be signed by the attending physician.
For evaluation and management encounters, the attending physician must document provision and/or supervision of all three key components (history, examination, and medical decision making). For example, the attending physician must document that he or she personally obtained or reviewed the history with the patient, personally examined the patient, and personally participated in the medical decision making with the resident physician. Inn contrast, the documentation in surgical procedures must include a statement by the attending surgeon attesting to his or her physical presence during the key portion(s) of the procedure in order to separately bill for the service rendered. In circumstances where a qualified resident physician is unavailable to assist an attending surgeon, another attending surgeon may assist using the -82 modifier. However, the operative note must document the absence of a qualified resident to act as an assistant at surgery.
Although the regulations for documenting services separately billed to Medicare by attending physicians seem fairly straightforward, they demonstrate the importance of clear documentation of the service provided if one seeks Medicare reimbursement. With the reduced training hours for resident physicians, it is anticipated that the attending physicians will play an even greater role in the direct care of patients. Consequently, it is imperative that they clearly understand the regulations and properly document their presence as well as the type of service provided.
Gregory J. Przybylski, MD, is director of neurosurgery at JFK Medical Center in Edison, N.J. He is on the faculty for the AANS coding and reimbursement courses.