Primary Care Exception Medicare Rule

5.0 EXCEPTION FOR EVALUATION AND MANAGEMENT (E&M) SERVICES FURNISHED IN CERTAIN PRIMARY CARE CENTERS

5.1 Exception for low level E&M services furnished in certain primary care centers:

For certain new and established patient office visit services (CPT codes 99201-99203, 99211-99213), the teaching physician is not required to see the patient, but rather need only to be immediately available when a resident performs these services in order for the teaching physician to bill Medicare Part B for his/her services.

Effective January 1, 2005, code G0334 (Initial preventive physical examination; face-to-face visit) is included under the primary care exception. This is limited to new patients during the first six (6) months of Medicare enrollment.

The only programs that may qualify for this exception are: Family Practice, General/Internal Medicine, Geriatric Medicine, Pediatrics, and Obstetrics and Gynecology.

Certain GME programs in Psychiatry may qualify in certain situations, such as 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 centers include comprehensive medical as well as psychiatric care.

The services must be furnished in a 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 direct GME payments to a teaching hospital by the hospital's Fiscal Intermediary. This requirement is not met when the resident is assigned to a physician's office away from the center or makes home visits.

5.2 Patients seen must be patients who consider the center to be the continuing source of their health care in which services are provided by residents under the medical direction of teaching physicians.

 


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