Teaching-Physician Billing: A Signature Does Not Establish Who Was There

Teaching physician billing fraud charges Medicare for an attending’s participation in a resident’s care that never happened. A resident may know who examined the patient, a nurse who was in the operating room, and a coder whose name reached the claim. When the billed participation exceeds what happened, those accounts can expose physician practice fraud. The work behind it is what Medicare pays for.

What Medicare Pays for in a Teaching Setting

Medicare pays for residents’ services through graduate medical education or reasonable-cost payments to the teaching setting. A separate physician fee-schedule claim requires the physician’s own service, the required participation in a resident’s work or a specific exception. We should not be paying an attending for participation that exists only on the bill.

The Centers for Medicare & Medicaid Services’ Medicare Claims Processing Manual defines residents to include interns and fellows in approved graduate medical education programs, as well as physicians authorized to practice only in a hospital. The incident-to billing and split/shared billing rules for other practitioners address different work than a resident’s training.

Students may document services, but the teaching physician must verify their findings and personally perform or re-perform the physical examination and medical decision making for the billed evaluation and management service. Medicare does not pay for a student’s own service.

What the Teaching Physician’s Visit Record Must Show

For an ordinary in-person evaluation and management visit involving a resident, the medical record must show that the teaching physician performed the service or was present for its key or critical portions. It must also show participation in managing the patient.

Medicare allows physician, resident or nursing notes to demonstrate presence during these visits. The comparison therefore reaches beyond the final attending signature to the resident’s entry, the treatment decisions and the account of who participated. The record must describe the particular service, patient and date. Unedited templates alone from both the resident and teaching physician are insufficient. We care about what that finished note says happened and whether the people doing the work can account for it.

Teaching-Physician Surgery and Overlapping Operations

Teaching-physician surgery billing requires presence during all critical or key portions and immediate availability throughout the procedure. The teaching surgeon determines which portions are key.

For two overlapping operations, the key portions cannot happen at the same time. The surgeon may become involved in the second procedure after the first procedure’s key portions finish and must personally document presence during the key portions of both. While operating elsewhere, the surgeon must arrange for another qualified surgeon to be immediately available to assist the resident in the first case.

Operating-room schedules, procedure times, resident entries and nursing notes let us examine what the attending’s account actually means. Two signatures tell us less than a timeline showing the key portions and who covered the remaining work. For three concurrent operations, the manual classifies the teaching surgeon’s role as supervision for the hospital, which is not payable as individual physician services under the fee schedule.

Some procedures require presence throughout. For minor procedures taking five minutes or less, with little decision making after the need is established, the teaching surgeon must attend the entire procedure. For nonsurgical endoscopy, the teaching physician must be present for the entire viewing, from insertion to removal of the endoscope. Watching a monitor from another room does not meet that requirement.

A Countersignature Does Not Establish Image Review

Medicare does not pay for a diagnostic interpretation when the teaching physician only countersigns the resident’s interpretation. When a resident prepares and signs the report, the teaching physician must indicate personal review of both the image and the resident’s interpretation, then agree with it or edit the findings. The image review, interpretation and signature are separate parts of the payment story.

The professional interpretation behind an imaging claim is work an insider can distinguish from the finished report. In the Alliance Family of Companies case, the whistleblowers alleged that EEG report labels shifted credit from the neurologist who interpreted the test to the provider who signed:

We see the same practical question in that allegation: whose work does the signature claim? For a resident’s interpretation, CMS supplies a specific answer about the review the teaching physician must actually perform.

Time-Based Services and High-Risk Procedures

For procedure codes based on time, the teaching physician must be present for the period claimed. Time the resident spends alone with the patient cannot be added to time spent together or to the teaching physician’s own patient time. For office and outpatient visits selected by total time, only the teaching physician’s qualifying activities count, including time present while the resident performs those activities.

The resident’s encounter times and the attending’s activity therefore answer different billing questions. A resident’s long visit cannot supply extra attending minutes. The applicable code and service date determine which activities count toward the claim.

For high-risk procedures requiring personal physician supervision, the teaching physician must be present with the resident for payment. Medicare lists cardiac catheterization and cardiovascular stress tests among its examples, so the attending’s whereabouts matter to those claims too.

The Primary-Care Exception Still Requires Involvement

The primary-care exception permits teaching physicians in qualifying programs to bill certain lower- and mid-level resident visits without being physically present. It applies in qualifying outpatient centers where residents’ patient-care time counts toward a teaching hospital’s direct graduate medical education payments.

Residents seeing patients under the exception must have completed at least six months of approved residency training. The teaching physician may supervise no more than four residents at once, must be immediately available and must have no competing responsibilities. A supervision assignment that conflicts with the attending’s other scheduled work matters to the bill.

The teaching physician must review the history, examination findings, diagnosis and treatment plan during or immediately after each visit. The medical record must document that review and direction.

Covered visit codes include 99202, 99203, 99211, 99212 and 99213, along with preventive and wellness codes G0402, G0438 and G0439. Higher-level visits require the general teaching-physician rules. Since January 1, 2022, office and outpatient visit levels under the exception are selected by medical decision making, so the resident’s time alone cannot raise the visit level.

Virtual Teaching-Physician Presence in 2026

For 2026, Medicare permanently permits virtual teaching-physician presence across all teaching settings for a three-way telehealth visit with the teaching physician, resident and patient in different locations. The final rule requires real-time audio and video for presence during the key portion. The service itself must be furnished virtually under this provision.

The medical record must identify whether the teaching physician was physically or virtually present and the specific portion covered virtually. Personal oversight and involvement in managing that portion remain required. The telehealth record and the resident’s note can show which part the attending joined and what the attending did.

A separate rural provision permits virtual presence for qualifying services at residency training sites outside metropolitan statistical areas. The manual also allows concurrent observation of certain psychiatric services through a one-way mirror or video equipment. For a health care insider, the service date and setting identify which kind of participation the bill required.

The Claim and the Participation Behind It

The submitted claim identifies the service for which Medicare payment was sought. The GC modifier certifies compliance with the applicable teaching-physician requirements. The GE modifier identifies services furnished under the primary-care exception, which also requires an attestation. Those billing statements can be compared with the records of who performed the work and the rule in force on that date.

For a surgical service, that comparison follows the key portions and the coverage arrangement. For an interpretation, it follows the image review and report. For a timed visit, it follows the teaching physician’s qualifying activities. A later signature cannot create work that never occurred.

If you know the instruction or recurring practice behind claims for participation that did not happen, we can build your strongest physician practice whistleblower case with you. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know Who Was There

If you are a resident, attending physician, nurse or healthcare billing professional who knows the claim overstates the attending’s work, speak with our whistleblower experts about that mismatch. We build the case with you around the service, the participation and the decisions behind the bill, and bring in Medicare billing whistleblower lawyers who understand teaching settings. We stay with you as your partners from the first conversation through the work of pursuing a recovery.