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Conditions to be met for Residency program


• The services must be furnished in a primary care center located in the 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 DGME payments to a teaching hospital. This requirement is not met when the resident is assigned to a physician’s office away from the primary care center or he or she makes home visits. The nonhospital entity should verify with the Fiscal Intermediary (FI) or A/B Medicare Administrative Contractor (MAC) that it meets the requirements of a written agreement between the hospital and the entity;

• Residents who furnish billable patient care without the physical presence of a teaching physician must have completed more than six months of an approved residency program;

• The teaching physician who submits claims under the exception must not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability;

• The teaching physician may include residents who have completed less than six months in an approved GME Residency Program in the mix of four residents under his or her supervision; however, the teaching physician must be physically present for the critical or key portions of these services (i.e., the primary care exception does not apply in the case of residents who have
completed less than six months in an approved GME Residency Program);

• The teaching physician must:

> Have no other responsibilities, including the supervision of other personnel, at the time services are furnished by residents;

> Have primary medical responsibility for patients cared for by residents;

> Ensure that the care furnished is reasonable and necessary;

> Review the care furnished by residents during or immediately after each visit. This must include a review of the patient’s medical history and diagnosis, the resident’s findings on physical examination, and the treatment plan (e.g., record of tests and therapies); and

> Document the extent of his or her participation in the review and direction of the services furnished to each patient; and

• The primary care center is considered the patients’ primary location for health care services. Residents must be expected to generally furnish care to the same group of established patients during their residency training.

The types of services furnished by residents under the primary care exception include:

• 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.

The residency programs most likely to qualify for the primary care exception are:

• Family practice;

• General internal medicine;

• Geriatric medicine;

• Pediatrics; and

• Obstetrics/gynecology.

Certain GME Programs in psychiatry may qualify for the primary care exception in special situations (e.g., when the program furnishes comprehensive care for chronically mentally ill patients). The range of services residents are trained to furnish, and actually furnish, at these primary care centers include comprehensive medical as well as psychiatric care.

Please see complete updates on Billing Requirements, Coverage and Limitations for Teaching Physicians and Residents

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