The Ultimate Primary Care Exception Attestation Checklist

Anyone who’s ever watched an episode of Scrubs has seen residents step into the role of primary caregiver. Those of us who work in Healthcare know that T.V. is fictional and in no way accurately represents our real day-to-day in the industry. However, in this case it’s true that sometimes residents can act as the primary caregiver.

Primary care exception allows a resident at a primary care center to act as the primary caregiver and see patients without supervision in order to learn medical decision making.

For more details, download our short eBrief, Primary Care Exception Rule: Just The Facts, for more on attestation, billing and coding, benefits and potential risks.

While there’s no special certification or formal application to qualify for primary exception, a primary care center must attest in writing that all of the following conditions are met:

Primary Care Attestation Checklist:

• The services were 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 direct Graduate Medical Education (DGME) payments to a teaching hospital.
  • Typically, the residency programs that are likely to qualify for this exception are family practice, general internal medicine, geriatric medicine, pediatrics and obstetrics/gynecology. Certain GME programs in psychiatry may qualify in cases where the program furnishes comprehensive care to the chronically mentally ill psychiatric patient (e.g., antibiotics are prescribed along with psychotropic medication management).
• The primary care center is considered the patient’s primary location for healthcare services.
• Residents providing billable patient care without direct supervision must have completed at least 6 months of an approved residency program.
• The teaching physician (under whom the billing is reported) cannot supervise more than 4 residents at a time and must direct the care from such proximity as to constitute immediate availability.
• The teaching physician must:
  • not have any other obligations during supervision of the residents (including supervising other personnel, e.g., non-physician practitioners),
  • ensure the care furnished is reasonable and necessary,
  • review the care furnished by the residents during or immediately after each visit, and
  • document the extent of the participation in the review and direction of the services furnished to each patient.
    • Either the resident or the teaching physician (or a combination of both) can document the support of medically necessary services, but it is the teaching physician’s responsibility to, at a minimum, document the review of the patient’s medical history and diagnosis, the resident’s findings on physical exam, and the treatment plan.

We all know that primary care exception runs a little more complex than just a simple checklist. There are qualifying details to consider, the exception is not allowed in the inpatient hospital setting, for example, and some complexities in the billing and coding of E/M services.