[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR415.174]



[Page 806]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 415_SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING 

PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS

--Table of Contents

 

            Subpart D_Physician Services in Teaching Settings

 

Sec. 415.174  Exception: Evaluation and management services furnished 

in certain centers.



    (a) In the case of certain evaluation and management codes of lower 

and mid-level complexity (as specified by CMS in program instructions), 

carriers may make physician fee schedule payment for a service furnished 

by a resident without the presence of a teaching physician. For the 

exception to apply, all of the following conditions must be met:

    (1) The services must be furnished in a center that is located in an 

outpatient department of a hospital or another ambulatory care entity in 

which the time spent by residents in patient care activities is included 

in determining intermediary payments to a hospital under Sec. Sec. 

413.75 through 413.83.

    (2) Any resident furnishing the service without the presence of a 

teaching physician must have completed more than 6 months of an approved 

residency program.

    (3) The teaching physician must not direct the care of more than 

four residents at any given time and must direct the care from such 

proximity as to constitute immediate availability. The teaching 

physician must--

    (i) Have no other responsibilities at the time;

    (ii) Assume management responsibility for those beneficiaries seen 

by the residents;

    (iii) Ensure that the services furnished are appropriate;

    (iv) Review with each resident during or immediately after each 

visit, the beneficiary's medical history, physical examination, 

diagnosis, and record of tests and therapies; and

    (v) Document the extent of the teaching physician's participation in 

the review and direction of the services furnished to each beneficiary.

    (4) The range of services furnished by residents in the center 

includes all of the following:

    (i) Acute care for undifferentiated problems or chronic care for 

ongoing conditions.

    (ii) Coordination of care furnished by other physicians and 

providers.

    (iii) Comprehensive care not limited by organ system, or diagnosis.

    (5) The patients seen must be an identifiable group of individuals 

who consider the center to be the continuing source of their health care 

and in which services are furnished by residents under the medical 

direction of teaching physicians.

    (b) Nothing in paragraph (a) of this section may be construed as 

providing a basis for the coverage of services not determined to be 

covered under Medicare, such as routine physical checkups.



[60 FR 63178, Dec. 8, 1995, as amended at 61 FR 59554, Nov. 22, 1996; 70 

FR 47490, Aug. 12, 2005]