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Teaching physician attestation rules govern when and how academic medical centers, teaching hospitals, and faculty practice plans may bill Medicare Part B under the Physician Fee Schedule (PFS) for Evaluation and Management (E/M) services, surgical procedures, and diagnostic interpretations involving interns, residents, and medical students. Because Medicare already subsidizes Graduate Medical Education (GME) resident salaries through Medicare Part A Direct GME (DGME) and Indirect Medical Education (IME) payments, federal regulations at 42 CFR § 415.170 through § 415.184 and the CMS Medicare Claims Processing Manual (Chapter 12, § 100) prohibit Part B payment for resident-involved services unless the teaching physician personally performs—or is physically present during—the critical or key portions of the service and documents that participation in the medical record.
Across academic inpatient wards, outpatient residency clinics, operating rooms subject to the global surgical package, and Department of Justice (DOJ) False Claims Act compliance audits, billing teams must distinguish standard Modifier GC supervision from the Primary Care Exception (Modifier GE under 42 CFR § 415.174) and apply CMS’s modernized verification rules for resident and medical student notes.
What Are the CMS Teaching Physician Rules Under 42 CFR § 415.172 and Medicare Claims Processing Manual Chapter 12 § 100?
Under 42 CFR § 415.172(a), if a resident participates in a service furnished in a teaching setting, Medicare Part B pays for the teaching physician’s service under the Physician Fee Schedule only if two core conditions are met:
- Personal Performance or Physical Presence During the Key/Critical Portion: The teaching physician must be present during the key or critical portion of any service or procedure for which payment is sought (or, for E/M services, must personally see the patient and participate in the management of the patient).
- Combined Medical Record Documentation: The combined entries into the medical record by the teaching physician and the resident must establish that the teaching physician was present during the critical or key portions of the service and directly participated in the management of the patient.
Service-Specific Teaching Physician Presence Requirements (CMS Chapter 12, § 100)
| Clinical Service Category | Regulatory Citation | Teaching Physician Presence & Attestation Requirement |
|---|---|---|
| Evaluation & Management (E/M) Services (Non-Primary Care Exception) |
42 CFR § 415.172; MCPM Ch. 12 § 100.1.1 |
The teaching physician must personally perform the E/M service OR be physically present during the critical or key portions of the service when performed by the resident, and must participate in the management of the patient. For time-based E/M codes, only the teaching physician’s own time (present with the patient or performing qualifying non-face-to-face activities) counts—resident solo time cannot be added. |
| Minor Procedures (< 5 Minutes) | 42 CFR § 415.172; MCPM Ch. 12 § 100.1.2 |
For procedures that take only a few minutes (5 minutes or less) to complete (e.g., simple suture, joint aspiration) and involve relatively little decision-making once the need is determined, the teaching surgeon must be physically present for the entire procedure. |
| Single Major Surgical / Endoscopic Procedures | 42 CFR § 415.172; MCPM Ch. 12 § 100.1.2 |
The teaching surgeon must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure. (For diagnostic endoscopy, the teaching physician must be present during the entire viewing—from insertion through withdrawal; reviewing a video or photo afterward is non-billable.) |
| Two Overlapping Surgeries | MCPM Ch. 12 § 100.1.2.A.2 | The critical or key portions of both procedures may not overlap. Once all critical portions of the first surgery are complete, the teaching surgeon may transition to the second room only if they designate another qualified physician to be immediately available for the first patient. For three concurrent surgeries, the teaching surgeon’s role is classified as supervisory GME (Part A) and is not payable under Part B. |
| Diagnostic Radiology & Other Diagnostic Tests | 42 CFR § 415.180; MCPM Ch. 12 § 100.1.4 |
Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician. If the resident prepares and signs the interpretation, the teaching physician must indicate that they have personally reviewed the image and the resident’s interpretation and either agree with it or edit the findings (a countersignature alone is insufficient). |
| Psychiatry Services | 42 CFR § 415.184; MCPM Ch. 12 § 100.1.5 |
The general physical presence requirement may be met by concurrent observation of the service through use of a one-way mirror, video equipment, or similar device, followed by post-session discussion with the resident. |
Note on Qualified Assistant at Surgery in Teaching Hospitals: Under 42 CFR § 415.190 and Modifiers 80, 81, 82, and AS, Medicare does not pay for an assistant at surgery in a teaching hospital that has a training program related to the surgical specialty unless no qualified resident was available (**Modifier 82**), exceptional medical circumstances existed, or the primary surgeon never involves residents in the preoperative, operative, or postoperative care of any of their patients.
When Do You Append Modifier GC (Resident Involvement Under Teaching Physician Direction) vs. Modifier GE (Primary Care Exception Under 42 CFR § 415.174)?
Every Medicare Part B claim for a physician service in which a GME intern, resident, or fellow participated (within the scope of their approved training program) must carry either Modifier GC or Modifier GE:
| Comparison Dimension | Modifier GC (“Service performed in part by a resident under the direction of a teaching physician”) |
Modifier GE (“Service performed by a resident without the presence of a teaching physician under the Primary Care Exception”) |
|---|---|---|
| Governing Regulation | 42 CFR § 415.172 | 42 CFR § 415.174 (Primary Care Exception) |
| Eligible Clinical Settings | All inpatient, observation, emergency department, surgical, and outpatient specialty/primary care teaching settings | Approved Hospital Outpatient Department / Freestanding Primary Care Centers only (Family Medicine, General Internal Medicine, General Pediatrics, Obstetrics/Gynecology, Geriatrics) that have attested in writing to the Medicare Administrative Contractor (MAC) |
| Billable CPT / HCPCS Codes | All E/M levels (99202–99205, 99212–99215, 99221–99239, 99281–99285, 99291–99292) and procedures |
Lower- and Mid-Level Outpatient E/M Only: • New patient: CPT 99202, 99203• Established patient: CPT 99211, 99212, 99213• Welcome to Medicare / AWV: HCPCS G0402, G0438, G0439(Level 4 and Level 5 visits— 99204, 99205, 99214, 99215—require physical presence and Modifier GC.) |
| Resident Training Requirement | Any PGY level (PGY-1 through fellow) | Resident must have completed more than 6 months of an approved residency program |
| Supervision Ratio & Duties | No fixed numerical cap, provided the teaching physician is physically present for the key/critical portion of each billed encounter | Teaching physician may supervise at most 4 residents at any given time, must be immediately available, may have no other responsibilities (cannot see their own separate schedule of patients concurrently), and must review the care during or immediately after each visit |
| Level Selection Basis | MDM or Teaching Physician’s personal Total Time | Medical Decision Making (MDM) only (CMS rules prohibit using time to select the E/M level for visits billed under the Primary Care Exception) |
How Did CMS Modernize Medical Student and Resident E/M Documentation Verification Rules (Allowing Review and Verification Rather Than Re-Documentation)?
Historically, CMS guidelines required teaching physicians to personally re-document key history, physical exam, and medical decision-making elements whenever a medical student authored a note, and mandated specific boilerplate attestation macros (e.g., “I have seen and examined the patient, reviewed the resident’s note, and agree with the plan”) on resident notes.
Through CMS Change Request (CR) 10412 (Transmittal 4068, effective March 2018) and the CY 2020 Medicare Physician Fee Schedule Final Rule (codified at 42 CFR § 410.20(e)), CMS enacted a broad Patients Over Paperwork burden-reduction rule across all Medicare Part B E/M services:
- General Principle of Review and Verification (42 CFR § 410.20(e)): When billing for an E/M service, the physician (or NPP) who bills for the service is not required to re-document information already included in the medical record by residents, medical students, nurses, or other members of the clinical team (or entered by the patient). Instead, the billing teaching physician may review and verify (sign and date) those notes rather than re-entering the history, physical exam, or medical decision-making narrative.
- What Must Still Be Performed in Person for Medical Student Notes: While the teaching physician no longer has to re-type a medical student’s note, a medical student is not a licensed practitioner. Therefore, to bill Medicare for an E/M visit documented by a medical student, the teaching physician (or a resident together with the teaching physician under
42 CFR § 415.172) must still personally perform (or re-perform) the physical examination and medical decision-making activities of the E/M service in the patient’s presence, and verify (sign and date) the student’s note. - What the Combined Record Must Establish for Audits: Whether the note is written by a resident, a medical student, or a procedure note template macro, the combined medical record must clearly show that the teaching physician met the physical presence requirement for the key/critical portions and participated in patient management. Note that a resident’s statement alone (“Case discussed with Dr. Smith, who examined the patient”) without the teaching physician’s own authenticated verification/signature is insufficient, just as a bare countersignature without any record of physical presence is non-compliant. (Similarly, when physicians work with NPs or PAs rather than GME residents, facility visits are governed by split/shared E/M visit rules rather than teaching physician rules.)
Frequently Asked Questions
What are the CMS Teaching Physician rules under 42 CFR § 415.172 and Medicare Claims Processing Manual Chapter 12 § 100?
Under 42 CFR § 415.172 and Medicare Claims Processing Manual Chapter 12 § 100, Medicare Part B pays for services involving a GME resident only when the teaching physician personally performs the service or is physically present during the critical or key portions of the service, participates in the management of the patient, and verifies that presence and participation in the combined medical record.
When do you append Modifier GC (resident involvement under teaching physician direction) vs. Modifier GE (Primary Care Exception under 42 CFR § 415.174)?
Modifier GC is appended to Medicare Part B claims whenever a resident performs part of a service under the physical presence and direction of a teaching physician under 42 CFR § 415.172. Modifier GE is used only in approved outpatient Primary Care Exception centers under 42 CFR § 415.174 when a resident with more than 6 months of GME training performs a lower- or mid-level E/M visit (CPT 99202–99203, 99211–99213, or G0402/G0438/G0439) selected by MDM without the teaching physician physically in the exam room, while the teaching physician supervises at most 4 residents and reviews the visit during or immediately afterward.
How did CMS modernize medical student and resident E/M documentation verification rules (allowing review and verification rather than re-documentation)?
Under CMS Change Request 10412 and the CY 2020 MPFS Final Rule (42 CFR § 410.20(e)), teaching physicians are no longer required to re-type or re-document E/M history, physical exam, or MDM notes entered into the medical record by residents, medical students, or other clinical staff. Instead, the teaching physician may review and verify (sign and date) the student’s or resident’s documentation, provided the teaching physician still personally performs (or is physically present for) the physical examination and medical decision-making activities required by 42 CFR § 415.172.
