---
kind: "range"
citation: "42 C.F.R. §§ 415.170–415.184"
title: "42"
from: "415.170"
to: "415.184"
count: 7
url: "https://uscodex.org/cfr/42/415.170..415.184"
---

# §415.170. Conditions for payment on a fee schedule basis for physician services in a teaching setting.


Services meeting the conditions for payment in [§ 415.102(a)](/cfr/42/415.102.md?p=a) furnished in teaching settings are payable under the physician fee schedule if—

- (a) The services are personally furnished by a physician who is not a resident; or
- (b) The services are furnished by a resident in the presence of a teaching physician except as provided in [§ 415.172](/cfr/42/415.172.md) (concerning physician fee schedule payment for services of teaching physicians), [§ 415.174](/cfr/42/415.174.md) (concerning an exception for services furnished in hospital outpatient and certain other ambulatory settings), [§ 415.176](/cfr/42/415.176.md) (concerning renal dialysis services), and [§ 415.184](/cfr/42/415.184.md) (concerning psychiatric services), as applicable.

# §415.172. Physician fee schedule payment for services of teaching physicians.

- (a) **General rule.** If a resident participates in a service furnished in a teaching setting, physician fee schedule payment is made only if a teaching physician is present during the key portion of any service or procedure for which payment is sought. In residency training sites that are located outside a metropolitan statistical area, physician fee schedule payment may also be made if a teaching physician is present during the key portion of the service, including for Medicare telehealth services, through audio/video real-time communications technology for any service or procedure for which payment is sought. For all teaching settings during the Public Health Emergency, as defined in [§ 400.200](/cfr/42/400.200.md) of this chapter, for the COVID-19 pandemic, if a resident participates in a service furnished in a teaching setting, physician fee schedule payment is made if a teaching physician is present during the key portion of the service including for Medicare telehealth services, through audio/video real-time communications technology for any service or procedure for which payment is sought.
  - (1) In the case of surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical portions of the procedure and immediately available to furnish services during the entire service or procedure.
    - (i) In the case of surgery, the teaching physician's presence is not required during opening and closing of the surgical field.
    - (ii) In the case of procedures performed through an endoscope, the teaching physician must be present during the entire viewing.
  - (2) In the case of evaluation and management services, except as otherwise provided in this [paragraph (a)(2)](#a-2), the teaching physician must be present in person during the portion of the service that determines the level of service billed. (However, in the case of evaluation and management services furnished in hospital outpatient departments and certain other ambulatory settings, the requirements of [§ 415.174](/cfr/42/415.174.md) apply.)
    - (i) In residency training sites that are located outside of a metropolitan statistical area, the teaching physician may be present through audio/video real-time communications technology during the portion of the service that determines the level of service billed. (However, in the case of evaluation and management services furnished in hospital outpatient departments and certain other ambulatory settings, the requirements of [§ 415.174](/cfr/42/415.174.md) apply.)
    - (ii) For all teaching settings during the Public Health Emergency, as defined in [§ 400.200](/cfr/42/400.200.md) of this chapter, for the COVID-19 pandemic, the teaching physician may be present through audio/video real-time communications technology during the portion of the service that determines the level of service billed. (However, in the case of evaluation and management services furnished in hospital outpatient departments and certain other ambulatory settings, the requirements of [§ 415.174](/cfr/42/415.174.md) apply.)
- (b) **Documentation.** Except as otherwise provided in this [paragraph (b)](#b), except for services furnished as set forth in [§§ 415.174](/cfr/42/415.174.md) (concerning an exception for services furnished in hospital outpatient and certain other ambulatory settings), [§§ 415.176](/cfr/42/415.176.md) (concerning renal dialysis services), and 415.184 (concerning psychiatric services), the medical records must document that the teaching physician was present at the time the service (including a Medicare telehealth service) is furnished. The presence of the teaching physician during procedures and evaluation and management services may be demonstrated by the notes in the medical records made by the physician or as provided in [§ 410.20(e)](/cfr/42/410.20.md?p=e) of this chapter.
  - (1) In residency training sites that are located outside of a metropolitan statistical area only, except for services furnished as set forth in [§§ 415.174](/cfr/42/415.174.md) (concerning an exception for services furnished in hospital outpatient and certain other ambulatory settings), 415.176 (concerning renal dialysis services), and 415.184 (concerning psychiatric services), the medical records must document whether the teaching physician was physically present or present through audio/video real-time communications technology at the time the service (including a Medicare telehealth service) is furnished. The medical records must contain a notation describing the specific portion(s) of the service for which the teaching physician was present through audio/video real-time communications technology. The presence of the teaching physician during procedures and evaluation and management services may be demonstrated by the notes in the medical records made by the physician or as provided in [§ 410.20(e)](/cfr/42/410.20.md?p=e) of this chapter.
  - (2) For all teaching settings during the Public Health Emergency, as defined in [§ 400.200](/cfr/42/400.200.md) of this chapter, for the COVID-19 pandemic, except for services furnished as set forth in [§§ 415.174](/cfr/42/415.174.md) (concerning an exception for services furnished in hospital outpatient and certain other ambulatory settings), 415.176 (concerning renal dialysis services), and 415.184 (concerning psychiatric services), the medical records must document whether the teaching physician was physically present or present through audio/video real-time communications technology at the time the service (including a Medicare telehealth service) is furnished. The medical records must contain a notation describing the specific portion(s) of the service for which the teaching physician was present through audio/video real-time communications technology. The presence of the teaching physician during procedures and evaluation and management services may be demonstrated by the notes in the medical records made by the physician or as provided in [§ 410.20(e)](/cfr/42/410.20.md?p=e) of this chapter.
- (c) **Payment level.** In the case of services such as evaluation and management for which there are several levels of service codes available for reporting purposes, the appropriate payment level must reflect the extent and complexity of the service when fully furnished by the teaching physician.

# §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 [§§ 413.75 through 413.83](/cfr/42/413.75..413.83.md).
  - (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; and
    - (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.
  - (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.
  - (6) The medical records must document the extent of the teaching physician's participation in the review and direction of services furnished to each beneficiary. The extent of the teaching physician's participation may be demonstrated by the notes in the medical records made by the physician or as provided in [§ 410.20(e)](/cfr/42/410.20.md?p=e) of this chapter to each beneficiary in accordance with the documentation requirements at [§ 415.172(b)](/cfr/42/415.172.md?p=b).
- (b) Nothing in [paragraph (a)](#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 check-ups.
- (c) For all teaching settings during the Public Health Emergency, as defined in [§ 400.200](/cfr/42/400.200.md) of this chapter, for the COVID-19 pandemic, the requirements in [paragraph (a)(3)](#a-3) of this section for a teaching physician to direct the care and then to review the services furnished by each resident during or immediately after each visit may be met through audio/video real-time communications technology.
- (d) In residency training sites that are located outside of a metropolitan statistical area only, the requirements in [paragraph (a)(3)](#a-3) of this section for a teaching physician to direct the care and then to review the services furnished by each resident during or immediately after each visit may be met through audio/video real-time communications technology.

# §415.176. Renal dialysis services.


In the case of renal dialysis services, physicians who are not paid under the physician monthly capitation payment method (as described in [§ 414.314](/cfr/42/414.314.md) of this chapter) must meet the requirements of §§ [415.170](/cfr/42/415.170.md) and [415.172](/cfr/42/415.172.md) (concerning physician fee schedule payment for services of teaching physicians).


# §415.178. Anesthesia services.

- (a) **General rule.**
  - (1) **For services furnished prior to January 1, 2010—** , an unreduced physician fee schedule payment may be made if a physician is involved in a single anesthesia procedure involving an anesthesia resident. In the case of anesthesia services, the teaching physician must be present during all critical portions of the procedure and immediately available to furnish services during the entire service or procedure. The teaching physician cannot receive an unreduced fee if he or she performs services involving other patients during the period the anesthesia resident is furnishing services in a single case. Additional rules for payment of anesthesia services involving residents are specified in [§ 414.46(c)(1)(iii)](/cfr/42/414.46.md?p=c-1-iii) of this chapter.
  - (2) **For services furnished on or after January 1, 2010—** , payment made under [§ 414.46(e)](/cfr/42/414.46.md?p=e) of this chapter if the teaching anesthesiologist (or different teaching anesthesiologists in the same anesthesia group practice) is present during all critical or key portions of the anesthesia service or procedure involved; and the teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) is immediately available to furnish anesthesia services during the entire procedure.
- (b) **Documentation.** Documentation must indicate the teaching physician's presence during all critical or key portions of the anesthesia procedure and the immediate availability of another teaching anesthesiologist.

# §415.180. Teaching setting requirements for the interpretation of diagnostic radiology and other diagnostic tests.

- (a) **General rule.** Physician fee schedule payment is made for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed or reviewed by a physician other than a resident.
  - (1) In residency training sites that are located outside of a metropolitan statistical area only, physician fee schedule payment may also be made for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by a resident when the teaching physician is present through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the interpretation of review of the diagnostic radiology test.
  - (2) For all teaching settings during the Public Health Emergency, as defined in [§ 400.200](/cfr/42/400.200.md) of this chapter, for the COVID-19 pandemic, physician fee schedule payment may also be made for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by a resident when the teaching physician is present through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the interpretation or review of the diagnostic radiology or diagnostic test.
- (b) [Reserved]

# §415.184. Psychiatric services.

- (a) Physician fee schedule payment is made for psychiatric services furnished under an approved GME program if the requirements of §§ [415.170](/cfr/42/415.170.md) and [415.172](/cfr/42/415.172.md) are met, including documentation, except that the requirement for the presence of the teaching physician during the service in which a resident is involved may be met by observation of the service by use of a one-way mirror, video equipment, or similar device.
- (b) In residency training sites that are located outside of a metropolitan statistical area, the requirement for the presence of the teaching physician during the service in which a resident is involved may be met through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the service.
- (c) For all teaching settings during the Public Health Emergency, as defined in [§ 400.200](/cfr/42/400.200.md) of this chapter, for the COVID-19 pandemic, the requirement for the presence of the teaching physician during the service in which a resident is involved may also be met through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the service.