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Madison Clinic Attending Memo

From Robert Harrington

Updated 6/9/10

Billing Responsibilities

This notice is to clarify the responsibilities of the attending physicians in the context of the new Medicare Billing Guidelines. All of you should have reviewed the new documentation requirements for inpatients. However, the requirements for documentation in an outpatient setting like the Madison Clinic (we are told that we are being viewed as a primary care clinic) are different in several instances:

  1. The Madison Clinic is a primary care clinic and as such attending may invoke the Primary Cre Exception (PCE) rule when supervising fellows and the occasional resident who has, as their continuity clinic, the Madison Clinic.  The PCE allows for attendings to bill for patient visits (up to a level 3) after reviewing cases with the fellow (or continuity resident) but does not require that the attending actually interview or examine the patient.   
  2. For interns/residents who rotate through Madison Clinic and who do NOT have their continuity clinic here, the primary care exemption does NOT apply.  Attendings must be present in the exam room during the “critical portion” of the patienst evaluated by rotating residents. Documentation of your exam findings and the other key components of the case must occur.
  3. To bill for a level of service > 3: Attendings must see the patient and perform key aspects of the history and exam.
  4. Supervision of Nurse Practitioners and Physician Assistants: There are no guidelines for the supervision of these providers or the documentation of that supervision (they are licensed to see patients independently of physicians). You should be available for consultation regarding their patients.
  5. You must supervise no more than 4 residents and fellows concurrently.
  6. You may not see your own patients when attending in the clinic and invoking the PCE rule.
  7. When working under the PCE rule you can have no other responsibilities besides mentoring continuity residents and fellows while in clinic. This includes direct supervision of students. Students may be involved in the care of patients who are seen primarily by a resident or fellow but can have no direct reporting responsibility to the attending.
  8. The practice of attending physicians seeing patients independently during a clinic session when the primary care exemption rule is in play is forbidden. Furthermore, it is NOT OK to see patients under these circumstances and "not charge the professional fee" as a way to get around the rule.
  9. Although we (The Madison Clinic) are not the "primary care provider" for post-exposure prophylaxis (PEP) patients we are allowed to bill for these patients in our clinic under the primary care exemption rule (PCER). When PEP patients are seen by residents or fellows it is perfectly appropriate to bill for those services. It is not appropriate for attendings to see PEP patients (or any patients for that matter) primarily when they are working under the PCER.

Key Points of Billing Compliance

1. Attending physicians: if billing under the Primary Care Exemption Rule – addend the resident/fellow note using the “Stamp” drop-down menu selection in ORCA: select “Primary Care Exemption Statement” – simply fill in the resident/fellow name.

This applies only to those residents and fellows who have a primary care HIV continuity panel here at Madison Clinic.

2. Attending physicians: when billing for patients you have seen and/or examined with a resident/fellow you can document your involvement using the “Stamp” drop-down menu,select: “Attending presence statement– Outpatient” – simply fill in the blanks. If you have performed the“key or critical component of care” yourself (for example – listened to the chest of patient with pneumonia) and the resident or fellow’s note justifies a level of billing higher than level 3, you can bill for that higher level even though you are working in a clinic like the Madison Clinic that is operating under the “Primary Care Exception rule”.


3. Procedures: when performing a procedure in the context of a visit when anything other than the procedure itself takes place – you should bill for the visit AND for the procedure using the procedure modifier code. This entails 1) selecting the visit level, 2) writing the number “25” in the box on the other side of the visit code for the level you just selected, 3) enumerating the procedure performed in the procedure section of the billing sheet to correspond with the same number of the diagnosis for which the procedure was performed.


Example #1: a patient presents with an abscess – you evaluate the abscess, decide it needs to be incised and then perform the I&D. You should bill for the visit (probably level 3), add the “25” modifier code in the box on the other side of the billing code, assign the diagnosis (abscess) number “1” and enumerate the I&D box with the number “1” in the procedure section of the billing sheet.
If, in the course of a visit, the only thing you do is perform a procedure – you should bill simply by checking the box for the procedure performed and leaving blank the visit level.


Example #2: A patient presents for a scheduled LP only (you had done the cognitive work that led to the decision to perform the LP at an earlier visit).

Bill by enumerating the box for the LP in the procedure section of the billing sheet. Check no other boxes (other than the diagnosis box(es)):
c. Gram’s stains, KOH preps, wet mounts and Pap smears are NOT procedures. They are categorized as labs. You can check that you’ve done them but do not assign them procedure status by adding the “25” procedure modifier code.
d. The billing sheets will be modified to reflect the correct classification of these items
e. Attendings: when mentoring a resident or fellow who performs a procedure – you CANNOT bill for that procedure unless you were present for the entire “minor”(takes less than 5 minutes) procedure or for the critical part of the “major”(takes more than 5 minutes) procedure.


4. Time-based billing. When billing using time-based billing you must specifically state that you have spent at least 50% (or more) of the appropriate face-to-face time (e.g., established outpatients: level 3 = 15 min, level 4 = 25 min, level 5 = 40) in counseling and coordination of care. Further, you must state those things you were discussing and/or coordinating.


Example #3: I spent 30 minutes in the room with the patient and at least 15 minutes was spent counseling him on the prevention of HIV.


5. All the Madison Clinic rooms and cubicles will be posted with simple tables and cards that provide the criteria for appropriate billing.


6. If you have questions – ask Bob Harrington or Kathleen Enniss

Thank you for your attention to these to these new guidelines. If you have questions or would like to discuss any of these requirements please call one of us.

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