> The new HCFA regulations which take effect July 1 are quite concerning
> as they pertain to the practice of emergency medicine in a training
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.
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.
Arno Zaritsky, M.D.
Children's Hospital of The King's Daughters
Eastern Virgnia Medical School
Norfolk, VA 23507
804-668-7486 FAX: 804-668-7313
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