1805 Medical assistance payment for services of teaching physicians in hospitals, clinics and emergency rooms

Title 55--PUBLIC WELFARE

DEPARTMENT OF PUBLIC WELFARE

[55 PA. CODE CH. 1141]

Medical Assistance Payment for Services of Teaching Physicians in Hospitals, Clinics and Emergency Rooms

[36 Pa.B. 5786]
[Saturday, September 16, 2006]

Scope

   This statement of policy applies to Medical Assistance (MA) enrolled physicians, acute care hospitals, outpatient hospital clinics and emergency rooms that provide teaching physician services in both the fee-for-service and managed care delivery systems.

Purpose

   The purpose of this statement of policy is to interpret the Department of Public Welfare's (Department) regulations regarding payment conditions for teaching physician services rendered to MA recipients in acute care hospitals, outpatient hospital clinics and emergency rooms. The Department's regulations are online on the Pennsylvania Code website at www.pacode.com.

Background

   The Department pays the actual provider of a service. See § 1101.75(a)(5) and (8) (relating to provider prohibited acts). The Department's regulations require that ''physicians' services billed to the Department be performed by the physician either personally or by a registered nurse, physician's assistant or midwife under the physician's direct supervision.'' See §§ 1141.53 and 1141.54 (relating to payment conditions for outpatient services; and payment conditions for inpatient services). MA regulations provide exceptions to this personal performance requirement in limited circumstances. See §§ 1150.52, 1150.54(a)(3) and 1150.55 (relating to anesthesia services; surgical services; and obstetrical services).

Discussion

   The Department has determined that the Medicare payment standards provide an acceptable foundation for MA reimbursement for services rendered by teaching physicians when a resident participates in the delivery of services. See 42 CFR 415.170--415.184.

   Medicare policy permits, with certain exceptions, payment to a teaching physician for services only if the ''teaching physician is present during the key portion of any service or procedure for which payment is sought.'' See 42 CFR 415.172(a) (relating to physician fee schedule payment for services of teaching physicians). In the case of surgery or a high-risk or complex procedure, the teaching physician shall be present during all critical portions of the procedure and be immediately available to furnish services during the entire procedure or service. See 42 CFR 415.172(a)(1). Consistent with Medicare policy, the Department considers a teaching physician as rendering a service when the teaching physician is present during the critical and key portions of a service in which a resident participates. The Medicare regulations provide the appropriate standards for determining whether a teaching physician is actually rendering a service.

   For outpatient clinic and emergency room services, services rendered by a resident are compensable provided that a teaching physician is readily available within that facility for immediate face-to-face consultation and assistance. The standards in Chapter 1221 (relating to clinic and emergency room services) are not affected by this statement of policy.

   Consistent with § 1101.51(e)(1)(iii) (relating to ongoing responsibilities of providers), medical entries must be signed and dated by the responsible licensed provider. Care rendered by ancillary personnel must be countersigned by the responsible licensed provider. Further, in accordance with regulation, the hospital shall bill the Department for the all inclusive visit fee or the procedure performed in the outpatient hospital clinic or emergency room under the payment rule in § 1221.51 (relating to general payment policy). The support and physician components of the emergency room visit are billed based on the billing arrangement as indicated on the facility's enrollment application.

Effective Date

   This statement of policy is effective upon publication in the Pennsylvania Bulletin.

Contact Person

   Questions and comments to this statement of policy should be directed to John Hummel, Regulations Coordinator, Office of Medical Assistance Programs, Bureau of Policy, Budget and Planning, Division of Regulatory and Program Development, [phone].

   (Editor's Note: Title 55 Pa. Code is amended by adding statements of policy in §§ 1141.53a and 1141.54a to read as set forth in Annex A.)

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note: 14-BUL-068. No fiscal impact; (8) recommends adoption.

Annex A

TITLE 55. PUBLIC WELFARE

PART III. MEDICAL ASSISTANCE MANUAL

CHAPTER 1141. PHYSICIANS' SERVICES

PAYMENT FOR PHYSICIANS' SERVICES

§ 1141.53a. Clinic and emergency room services personal performance--statement of policy.

   (a)  Consistent with 42 CFR 415.152 (relating to definitions), a teaching physician is a physician (other than another resident) who involves residents in the care of that teaching physician's patients.

   (b)  Clinic services rendered by a resident are compensable when a teaching physician is readily available for immediate face-to-face consultation and assistance.

   (c)  Emergency room services rendered by a resident are compensable when a teaching physician is readily available for immediate face-to-face consultation and assistance.

   (d)  Consistent with 42 CFR 415.180 (relating to teaching setting requirements for the interpretation of diagnostic radiology and other diagnostic tests), the interpretation of diagnostic radiology and other diagnostic tests is compensable. Documentation must indicate that the teaching physician personally performed the interpretation or reviewed the resident's interpretation with the resident.

§ 1141.54a. Acute care hospitals and their short procedure unit services personal performance--statement of policy.

   (a)  Consistent with 42 CFR 415.152 (relating to definitions), a teaching physician is a physician (other than another resident) who involves residents in the care of that teaching physician's patients.

   (b)  The Department will reimburse for teaching physician services rendered in acute care hospitals or their short procedure units in accordance with the Medicare standards governing payment for professional services rendered by teaching physicians in 42 CFR 415.170--415.184, except as provided in § 1141.53a (relating to clinic and emergency room services personal performance--statement of policy).

[Pa.B. Doc. No. 06-1805. Filed for public inspection September 15, 2006, 9:00 a.m.]