TMPPM 2007 >36.3.1.1 Teaching Attending Physician and Resident Physician

The roles of the teaching attending physician and resident physician occur in the context of an accredited graduate medical education (GME) training program.

The attending physician is the Medicaid-enrolled physician who is professionally responsible for the particular services that were provided and are being submitted for reimbursement; the physician must be affiliated and in good standing with an accredited GME program and must possess all appropriate licensure.

In all cases, the client's medical record must clearly document that the teaching attending physician provided identifiable supervision of the resident. As defined below, the supervision must be direct or personal depending on the setting and the clinical circumstances:

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Personal supervision means that the teaching attending physician must be in the building of the office or facility when and where the service is provided.

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Direct supervision means that the teaching attending physician must be physically present in the room when and where the service is being provided.

The teaching attending physician must provide direct supervision during all medically-complex situations, dangerous procedures, or major surgery. A service or procedure is complex or dangerous if deviation from the expected technique at the time the procedure or service is performed presents a medically-reasonable and immediate risk to the patient's life or health. This criterion applies regardless of the place or setting of care.

The teaching attending physician must provide medically appropriate, identifiable personal supervision for all other services that do not require direct supervision.

The following prerequisites apply when the teaching attending physician submits claims for services performed, in whole or in part, by the resident physician:


Prerequisites for the Inpatient Hospital Setting, the Outpatient Hospital Setting, and Surgical Services and Procedures
Services provided in an outpatient setting. For services provided in an outpatient setting, the teaching attending physician must demonstrate that personal supervision was provided. The following tasks must be performed and their completion must be documented in the patient's medical record before the claims are submitted for consideration of reimbursement: •Review the patient's history and physical examination. •Confirm or revise the patient's diagnosis. •Determine the course of treatment to be followed. Exception for E/M services furnished in certain primary care centers. Teaching attending physicians that meet the primary care exception under Medicare are allowed to bill for low-level and mid-level E/M services for residents. Facilities that meet the primary care exception under Medicare may bill the Texas Medicaid Program, Family Planning, or the Children with Special Health Care Needs (CSHCN) Services Program for new patient services (procedure codes 1-99201, 1-99202, and 1-99203) and established patient services (procedure codes 1-99211, 1-99212, and 1-99213). Note: All services provided in an outpatient setting that do not qualify for the exception above require that the attending teaching physician examine the patient.
Services provided in an inpatient setting. For services provided in an inpatient setting, the teaching attending physician must demonstrate that medically-appropriate supervision was provided. The following tasks must be performed and their completion must be documented in the patient's medical record before the claims are submitted for consideration of reimbursement. The documentation must be made in the same manner as required by federal regulations under Medicare: •Review the patient's history, review the resident's physical examination, and examine the patient within a reasonable period of time after the patient's admission and before the patient's discharge. •Confirm or revise the patient's diagnosis. •Determine the course of treatment to be followed. •Document the teaching attending physician's presence and participation in the major surgical or other complex and dangerous procedure or situation.
Surgical services and procedures. The teaching attending surgeon is responsible for the beneficiary's preoperative, operative, and postoperative care. The teaching attending physician must demonstrate that medically appropriate supervision was provided. The following tasks must be performed and their completion must be documented in the patient's medical record before the claims are submitted for consideration of reimbursement. The documentation must be made in the same manner as required by federal regulations under Medicare: •Review the patient's history, review the resident's physical examination, and examine the patient within a reasonable period of time after the patient's admission and before the patient's discharge. •Confirm or revise the client's diagnosis. •Determine the course of treatment to be followed. •Document the teaching attending physician's presence and participation in the major surgical or other complex and dangerous procedure or situation.
Important: Reimbursement may be reduced, denied, or recouped if the prerequisites are not documented in the medical record. The documentation must be made in the same manner as required by federal regulations under Medicare.