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Primary Care Exception Rule: Just the Facts - Healthicity

E-BRIEF SERIES. Primary care Exception Rule: just the Facts Lara Smith CPC, CMEC | REGIONAL AUDIT DIRECTOR. E-BRIEF SERIES. Primary care Exception Attestation Checklist Understanding Primary care In the Primary care setting, it's possible to report low to mid-range E/M services Exception performed by a resident without direct The CMS defines Primary care Exception : teaching physician supervision. However, this doesn't mean that the teaching physician is uninvolved. Since the service is reported An Exception within an under the teaching physician's name, he/. approved GME Program that she still has to ensure the services rendered are appropriate and medically necessary.

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Transcription of Primary Care Exception Rule: Just the Facts - Healthicity

1 E-BRIEF SERIES. Primary care Exception Rule: just the Facts Lara Smith CPC, CMEC | REGIONAL AUDIT DIRECTOR. E-BRIEF SERIES. Primary care Exception Attestation Checklist Understanding Primary care In the Primary care setting, it's possible to report low to mid-range E/M services Exception performed by a resident without direct The CMS defines Primary care Exception : teaching physician supervision. However, this doesn't mean that the teaching physician is uninvolved. Since the service is reported An Exception within an under the teaching physician's name, he/. approved GME Program that she still has to ensure the services rendered are appropriate and medically necessary.

2 Applies to limited situations However, when done correctly, this Exception where the resident is the to the teaching rule could translate to Primary caregiver and the more patients treated than in a typical faculty physician sees the residency program and also a better learning experience for those residents. patient only in a consultative role (that is, those residency There isn't an application process or pre- programs with requirements approval in order to start operating under the Primary care Exception . However, a that are incompatible with a Primary care center must attest in writing physical presence requirement).

3 That all of the following conditions are met: In such Programs, it's beneficial for the resident to see patients without supervision to learn medical decision making.. E-BRIEF SERIES. Primary care Exception Attestation Checklist: The services were furnished in a Residents providing billable patient direction of the services furnished to Primary care center located in the care without direct supervision must each patient. outpatient department of a hospital have completed at least 6 months of or another ambulatory care entity in an approved residency program. Either the resident or the teaching which the time spent by residents in physician (or a combination of patient care activities is included in The teaching physician (under whom both) can document the support of determining direct Graduate Medical the billing is reported) cannot supervise medically necessary services, but it is Education (DGME) payments to a more than 4 residents at a time the teaching physician's responsibility teaching hospital.

4 And must direct the care from such to, at a minimum, document the proximity as to constitute immediate review of the patient's medical Typically, the residency programs availability. history and diagnosis, the resident 's that are likely to qualify for this findings on physical exam, and the Exception are family practice, general The Teaching Physician Must: treatment plan. internal medicine, geriatric medicine, not have any other obligations during pediatrics and obstetrics/gynecology. supervision of the residents (including Certain GME programs in psychiatry supervising other personnel, , non- may qualify in cases where the physician practitioners), program furnishes comprehensive care to the chronically mentally ensure the care furnished is ill psychiatric patient ( , reasonable and necessary, antibiotics are prescribed along with psychotropic medication review the care furnished by the management).

5 Residents during or immediately after each visit, and The Primary care center is considered the patient's Primary location for document the extent of the healthcare services. participation in the review and E-BRIEF SERIES. Table of Risk Types Of Services Residents Will Likely Perform And Level Of Risk Residents in a Primary care Exception clinic would likely be seeing the same patients repeatedly over the time of their residency. As such, they would perform the following types of services: Acute care for undifferentiated problems or chronic care for ongoing conditions, including chronic mental illness.

6 Coordination of care furnished by other physicians and providers; and Comprehensive care not limited by organ system or diagnosis. Keeping in mind the first point, Acute care for undifferentiated problems , the types of problems the resident is qualified to manage without a teaching physician's direct presence will fall into the lower risk categories on the medical decision making table of risk. E-BRIEF SERIES. Billing And Coding of Outpatient portions of the services (see the CMS Conclusion Claims Processing Manual, Chapter E/M Services Remember, Primary Exception Rule is an 12, Section 100 for detailed teaching As a result, the highest level of service a physician guidelines).

7 Exception within an approved GME Program resident can bill for outpatient E/M services that applies to some situations where a is a 3 (99201-99203 and 99211-99213). The GE modifier signifies to Medicare resident can act as the Primary caregiver. Additionally, in recent years, CMS added the that the services were performed by While there isn't an application process, the Initial Preventive Physical Examination, or a resident without the presence of a Primary care center must attest in writing IPPE (G0402), and both initial (G0438) and teaching physician under the Primary that all of a number of conditions are met.

8 Subsequent Annual Wellness Visits, or AWV care Exception . This should be appended Residents will usually perform services in the (G0439), services to the list of allowed codes to the levels of service above when all of medical decision making low risk categories under PCE. Documentation for the IPPE and the requirements have been met. like a stable chronic illness. AWV services are very different from a sick . visit billed with new or established patient GC modifier is used when the service has It's crucial to remember that the service visit codes, so be sure your providers know been performed in part by a resident is reported under the teaching physician's the requirements of both.

9 Under the direction of a teaching name, so he/she still has to ensure that the physician (not Primary care Exception ). services rendered were appropriate and medically necessary. The benefit to this Primary Exception Rule: This Exception is not allowed in the Exception is that the rule could translate Important Qualifying Details To inpatient hospital setting. to more patients treated than in a typical Consider: residency program and it's also a better learning experience for those residents This is a Medicare concept, though some regarding medical decision making. payers will follow Medicare's lead.

10 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 E-BRIEF SERIES. AUTHOR BIO. Lara Smith CPC, CEMC. Lara has over 10 years of experience in the healthcare billing and coding industry. She currently performs secondary audit reviews and provides education to clients in various parts of the country as a Regional Audit Director with Healthicity Audit Services. Lara has previously served as President and President-Elect in the Mooresville, NC chapter.


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