Frequently Asked Questions

1. When scheduling for Primary Care Clinics, what type services should be scheduled?

Answer: Routine, problem focused visits. Remember Primary Care Exception (PCE) only applies to low-mid level E/M services (99201-99203 and 99211-99213), Medicare Initial Preventive Physical Exam (IPPE) (G0402), Annual Wellness Visit (AWV) (G0438 & G0439) and now the THSteps Well-Child Visits for Texas Medicaid Well Child visits (99381-99385 and 99391-99395). Any other scheduled services must be provided under the General Teaching Physician rule outside the Primary Care setting.

References: BC Policy 4.2 Teaching Physician Requirements for Evaluation & Management Services Provided under Medicare's Primary Care Exception Rule: http://www.ttuhsc.edu/billingcompliance/documents/BCP_4.2_TPPCE_02-12.pdf CMS Transmittal 1780, Section 15016, Supervising Physicians in a Teaching Setting: https://www.cms.gov/Transmittals/Downloads/R1780B3.pdf.

2. When a patient is seen as an outpatient at the hospital, does the Primary Care Exception rule apply?

Answer: Not for TTUHSC. They need to be seen in a clinic setting - it is a location that the patient perceives as the place they receive their primary, routine care. Outpatient hospital services provided by our physicians in a hospital outpatient department do not qualify as Primary Care Exception. Now, if we lease space in the hospital and operate it as a physician clinic, then the Primary Care Exception might apply if the other criteria are met.

References: BC Policy 4.2 Teaching Physician Requirements for Evaluation & Management Services Provided under Medicare's Primary Care Exception Rule: http://www.ttuhsc.edu/billingcompliance/documents/BCP_4.2_TPPCE_02-12.pdf CMS Transmittal 1780, Section 15016, Supervising Physicians in a Teaching Setting: https://www.cms.gov/Transmittals/Downloads/R1780B3.pdf.

3. Can Specialty Clinics be scheduled as Primary Care Exception Clinics?

Answer: No. The types of services that can be provided under the Primary Care Exception are limited to:

• acute care for undifferentiated problems or chronic care for ongoing conditions including chronic mental illness;
• coordination of care furnished by other physicians and providers; and
• comprehensive care not limited by organ system or diagnosis.

Specialty physicians cannot fit within the Primary Care Exception. CMS states that practices such as Family Medicine, General Internal Medicine, Geriatric Medicine, Pediatrics and OB/GYN are allowed under the Primary Care Exception

References: BC Policy 4.2 Teaching Physician Requirements for Evaluation & Management Services Provided under Medicare's Primary Care Exception Rule: http://www.ttuhsc.edu/billingcompliance/documents/BCP_4.2_TPPCE_02-12.pdf CMS Transmittal 1780, Section 15016, Supervising Physicians in a Teaching Setting: https://www.cms.gov/Transmittals/Downloads/R1780B3.pdf.

4. When the Primary Care Exception Rule says the Teaching Physician can have no other responsibilities, what does that mean?

Answer: The Teaching Physician cannot provide any other billable service which includes supervising non-physician personnel in a Primary Care Exception Clinic. CMS states practices such as Family Medicine, General Internal Medicine, Geriatric Medicine, Pediatrics and OB/GYN may meet criteria under the Primary Care Exception Rule. Specialty Clinics such as Neurology and General Surgery do not meet criteria for Primary Care Exception Clinics.

References: BC Policy 4.2 Teaching Physician Requirements for Evaluation & Management Services Provided under Medicare's Primary Care Exception (PCE) Rule: http://www.ttuhsc.edu/billingcompliance/documents/BCP_4.2_TPPCE_02-12.pdf CMS Transmittal 1780, Section 15016, Supervising Physicians in a Teaching Setting: https://www.cms.gov/Transmittals/Downloads/R1780B3.pdf.

5. If a Teaching Physician does not participate in the fracture care of a patient provided by a resident, and did not see the patient until some date following the resident's service, how should the Teaching Physician bill for services of the patient's follow-up visit?

Answer: Because the Teaching Physician did not participate in and did not report fracture care for payment by Medicare, no "global" period exists for the physician's services associated with the fracture care. Therefore, the Teaching Physician may report E/M services as usual without modifiers.

Reference: Quote from Debra Patterson, M.D., Trailblazer's Medical Director, August 4, 2008

1. What is the risk associated with copy and paste functionality in the EMR/EHR?

Answer: If copy and paste functionality is used, the billing provider should make sure the note is edited and/or modified to satisfy the specific needs of the patient's encounter it was copied to. The risk usually manifests itself in the form of contradictory information in the note and/or large portions of the notes being too similar from one date of service to the next. This type of functionality is addressed in BC Policy 7.2, EHR Cloning (Copy & Paste) Functions.

Reference: http://www.ttuhsc.edu/billingcompliance/documents/BCP_7.2_Clone_071510.pdf

2. Why is the paper-based medical record standard applied to an EHR? How can the EMR/EHR system be the same as a paper based system?

Answer: The requirements are the same for both systems from a billing standpoint; however, the execution is handled differently in an EMR, depending on the application. For example, the authentication methodology is structured differently by sign-in. Trailblazer uses the same methods to evaluate the accuracy of the billing, whether the documentation is electronic or paper-based.

1. Should the documentation from medical students be handled differently?

Answer: Yes. Medical students' documentation of ROS and PFSH are the only useable parts of documentation to support a bill. The majority of the issue is structuring a system to clearly identify the documentation produced by the medical student.

Reference: Medicare Internet Only Manual, Section 100.1.1.B, Page 158. http://www.cms.gov/manuals/downloads/clm104c12.pdf

2. What is a scribe?

Answer: A scribe is a human recording device, offering no input, thought, etc. of his/her own. The scribe quite literally only writes what he/she is told to write.

Reference: BC Policy 4.0 Basic Documentation Standards for Billing Purposes http://www.ttuhsc.edu/billingcompliance/documents/BCP_4.0_Doc_Standards.pdf

1. What is the deadline for documentation and/or completing the medical record and why is timely completion such as issue?

Answer: The generally applied standard according to internal policy is 14 days from the DOS; however, the absolute standard is that the service should be completed prior to the billing date, whenever that may be.

Reference: Ambulatory Clinic Policy 5.1 can be referenced at http://www.ttuhsc.edu/som/clinic/policies/ACPolicy5.01.pdf

2. Do we need modifier 25 when billing for smoking cessation counseling and a new patient visit on the same day?

Answer: Yes. A medically necessary E/M service on the same day as smoking and tobacco use cessation counseling service is allowed when clinically appropriate. Modifier 25 should be added to the E/M service to show it is separate from the smoking cessation counseling.

Reference: E/M Manual, page 65. Also see CMS IOM Pub. 100-04, Chapter 18, Section 150 http://www.cms.gov/manuals/downloads/clm104c18.pdf

3. What does modifier 25 mean?

Answer: It means a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.

Reference: CMS IOM Pub. 100-04, Chapter 12, Section 40 for surgical coding. Also see Section 30.6.6 for E/M coding http://www.cms.gov/manuals/downloads/clm104c12.pdf

4. Our group has physicians with different specialties. How do we bill for unrelated visits within the global surgical period?

Answer: When different physicians in a group practice treat the same patient, the group bills for the entire global package (if the physicians reassign benefits to the group). E/M services are allowed during a global fee period if the claim documentation shows that the visit is for a diagnosis unrelated to the original surgery or meets one of the exceptions. Exceptions include immunosuppressive therapy for organ transplants or critical care services (99291-99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.

For medically necessary visits unrelated to the original surgery, but within the global period.

• If the unrelated E/M is by a different doctor within the group (no matter what the specialty), modifier 24 is not needed.
• If the unrelated E/M is by the same doctor who performed the surgery within the postoperative period, modifier 24 is appropriate.

Reference: CMS IOM Pub. 100-04, Chapter 12, Section 30.6.6  http://www.cms.gov/manuals/downloads/clm104c12.pdf

TrailBlazer Evaluation and Management Services manual: http://www.trailblazerhealth.com/Publications/TrainingManual/EvaluationandManagementServices.pdf

 back to top