Arno Zaritsky, M.D. wrote:
> I am not certain how much impact these regulations have for pediatric
> emergency medicine physicians. As you probably know, the HCFA
> guidelines apply only to Medicare patients. The presumption is that
> they may be applied by commercial insurors as well. The purpose of
> the new rules is to eliminate "double billing" from the perspective
> of the federal government. The Feds pay a certain amount to graduate
> medical education (GME) centers designed to cover the cost of
> residents in that setting. If the resident alone provides the
> service, the Feds feel as if they have already paid for that service.
> There has been abuse in the past, such as surgery performed entirely by
> a resident, but billed by an attending.
> In the ED, I think this is less of a problem since an attending is
> usually present. If your ED leaves a resident uncovered late at
> night, then you will have a problem billing for that service,
> provided it is a Medicare service. To my knowledge, most states do
> not provide identified supplement funding for pediatric resident
> positions, since they do not provide Medicare coverage. Some states
> increase their Medicaid payments to GME centers to help defray the
> costs of pediatric residents. The bottom line, IMHO is that the
> argument used by the Feds in the HCFA ruling does not clearly apply
> to pediatric patient care.
Currently true, but I think it is very likely that regulations adopted for
Medicare patients will soon be used by Medicaid and other insurers.
> Under the guidelines published in the Dec 8, 1995 Federal Register
> (you can find it on the web at a number of sites) I think emergency
> medicine supervising physians could argue that they can supervise up
> to four residents at a given time, that they must direct the care
> from such proximity as to constitute immediate availability; the
> teaching physician must have no other responsibilities other than
> supervision; they must review with each resident during or immediately
> following each visit the medical history, physical examination,
> diagnosis and record of tests, therapies, etc.; and document his/her
> participation in the review and direction of services provided to the
> patient. Whew! If all of these things are done, you should be safe in
> billing for your service.
> I hope this helps.
It certainly does, thanks for posting it to this list. In discussing this
yesterday, a representative of the American Association of Medical Colleges by
and large agrees with your assessment. Some additional details:
1) any procedures performed by medical students are not billable under Part B
2) as indicated above, the supervision of procedures must be on-site, and
payment is made only if a teaching physician is present during the key portion
of any service or procedure for which payment is sought.
3) exceptions to the billing regularions above apply to certain primary care
must be furnished in out-patient cernters or other ambulatory entities,
residents must have completed at least 6 months of training,
no more than 4 residents directed by the teaching physician at any one time,
patients must consider the center their source of continuing health care.
The URL for the PED-EM-L Web Page is: