Introduction

In the August 18, 2006 Federal Register (71 Fed Reg. 47870) the regulations for counting FTE residents and the required documentation for FTE residents to be allowable were clarified. 

Proper Documentation Must be Maintained for the Fiscal Intermediaries

Proper documentation is required so that Medicare fiscal intermediaries can determine where and when a resident is training and to allow the fiscal intermediary to make payment to the hospital based on the time the resident spends at the hospital, which may be a percentage of the total time trained. A rotation schedule is the primary documentation that can be used to support the direct GME and IME resident counts but other similar documentation may be acceptable.

Hospitals are not permitted to decide among themselves how their FTEs will be counted. A hospital may not count a greater number of FTE residents than are actually being trained at the hospital (or its non-hospital sites) during the year. Each hospital must have documentation which demonstrates, for the entire cost reporting period, the amount of time that the resident trained at the hospital and, if applicable, a non-hospital site. Furthermore, to the extent that residents train in non-hospital sites, the hospital claiming the FTEs in the non-hospital site must meet the requirements at 42 CFR § 413.78(e).

In order to ensure that FTEs are being properly counted, hospitals are required to furnish specific documentation to support the number of FTE residents included in the hospital's FTE count. 42 CFR § 413.75(d) specifies the requirements concerning documentation of FTE residents.

What Information Must be Maintained?

Proper documentation must include the following information: The name and social security number of the resident; the type of residency program in which the individual participates and the number of years the resident has completed in all types of residency programs; the dates the resident is assigned to the hospital and any hospital-based providers (similar to the rotation schedule); the dates the resident is assigned to other hospitals, or other freestanding providers, and any non-provider setting during the cost reporting period, if any; and the name of the employer paying the resident's salary. In addition, the documentation should include the name of the medical, osteopathic, dental, or podiatric school from which the resident graduated and the date of graduation, and whether the resident is a foreign medical graduate, including documentation concerning whether the resident has satisfied the regulatory requirements for foreign medical graduates at 42 CFR § 413.80.  The information must be certified by an official of the hospital and, if different, an official responsible for administering the residency program.  Again, proper documentation on where and when a FTE resident is training during a cost reporting period is essential in order for the hospital to receive direct GME and IME payments based on the correct number of FTE resident(s).  Inaccurate, incomplete, or inappropriate documentation will lead to Medicare disallowing certain FTE residents from being counted for purposes of direct GME and IME payments.

IRIS Shortcomings: Why IRIS Doesn’t Satisfy the Documentation Requirements

Many of the above referenced items that must be maintained are included on the IRIS listing. However, the IRIS listing does not contain all of the specified documentation cited under 42 CFR § 413.75(d) and § 412.105(f). Furthermore, the IRIS listing does not serve as the evidence/documentation that supports the accuracy of the FTE resident counts reported in the cost report. Hospitals prepare the IRIS listing using actual records (for example, rotation schedules or similar documentation) that could be proper evidence/documentation to support the accuracy of the FTE resident counts reported in the cost report. In addition, the FTE resident counts computed using the IRIS information do not always match the FTE resident counts reported in the related cost reports. Thus, the IRIS is not, in itself, a sufficient mechanism for hospitals to meet their obligation to furnish information required under 42 CFR § 413.75(d) to support the FTE resident counts reported in the cost report. Rotation schedules or other similar documentation should stand as the primary evidence to support hospitals' FTE resident counts. Therefore, in addition to submitting the IRIS report, the hospital must submit other documentation elements specified in 42 CFR § 413.75(d), and those must be certified by a hospital or GME program official.

Documenting Residency Time Spent in Non-patient Care Activities as Part of Approved Residency Programs

It is important for hospitals to be able to document the activities in which residents are engaged because there are certain activities that are not allowable for direct GME or IME payment purposes, even though those activities may be performed as part of an approved residency program.

With respect to training in non-hospital settings, the time that residents spend in non-patient care activities as part of an approved program, including didactic activities, cannot be included in a hospital's direct GME or IME FTE resident count. This longstanding policy, which can be found at 42 CFR § 412.105(f)(1)(ii)(C) and § 413.78(e), is based on the statutory requirements for counting FTE residents training in non-hospital sites.

1. Non-Hospital Settings and GME
   For the purpose of direct GME payments, providers have been allowed since July 1, 1987, to count the time residents spend training in non-hospital sites under certain conditions. Section 1886(h)(4)(E) of the Act specifies that the implementing regulations concerning computation of direct GME for training in non-hospital sites “shall provide that only time spent in activities relating to patient care shall be counted and that all the time so spent by a resident under an approved medical residency training program shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed, if the hospital incurs all, or substantially all, of the costs for the training program in that setting”.
   
2. Non-Hospital Settings and IME
   For IME payment purposes, hospitals were first allowed to count the time residents spend training in non-hospital sites for discharges occurring on or after October 1, 1997. Section 1886(d)(5)(B)(iv) of the Act was amended by Pub. L. 105-33 in 1997 to provide that “all the time spent by an intern or resident in patient care activities under an approved medical residency program at an entity in a non-hospital setting shall be counted towards the determination of full-time equivalency if the hospital incurs all, or substantially all, of the costs for the training program in that setting”.
   

Didactic Activities are Not Counted as Patient Care

The plain meaning of patient care activities would certainly not encompass didactic activities. Rather, the plain meaning refers to the care and treatment of particular patients, or to services for which a physician or other practitioner may bill. Time spent by residents in such patient care activities may be counted for direct GME and IME payment purposes in the non-hospital site. Time spent by residents in other activities in the non-hospital site that do not involve the care and treatment of particular patients, such as didactic or “scholarly” activities, is not allowable for direct GME and IME payment purposes.

For direct GME payment purposes, under 42 CFR § 413.78(a), “residents in an approved program working in all areas of the hospital complex may be counted.” As explained in the September 29, 1989 Federal Register (54 FR 40286), the hospital complex consists of the hospital and the hospital-based providers and subproviders. Therefore, the distinction between patient care activities and non-patient care activities is not relevant to direct GME FTE count determinations when the residents are training in the hospital complex. However, for IME payment purposes, consistent with the regulations at 42 CFR § 413.9, only time spent in patient care activities in the hospital may be counted. It has been CMS’ longstanding policy that, regardless of the site of training, that you “do not include residents in the IME count to the extent that the residents are not involved in furnishing patient care”.

CMS Develops the One Workday Standard for Documenting Didactic Activities

Hospitals have been inconsistent in their reporting of non-patient care activities, either because of confusion surrounding CMS’ FTE-counting policy, or because of differing approaches to developing and maintaining rotation schedules.  Therefore, from an administrative perspective CMS has chosen to distinguish documentation requirements for cost reporting periods beginning prior to October 1, 2006, and cost reporting periods starting on or after October 1, 2006.  For cost reporting periods beginning on or after October 1, 2006, to ensure consistent reporting by hospitals, all teaching hospitals are required to document residents' time at some minimum level of detail.  Specifically, for cost reporting periods beginning on or after October 1, 2006, for training occurring either in the hospital or in non-hospital settings, CMS is instituting a “one workday” threshold for documentation purposes. CMS is not requiring that hospitals overhaul their current rotation schedules, nor are they mandating that rotation schedules be maintained in one-day increments.

Do Not Count Didactic Activities Encompassing an Entire Workday

If a resident's workday consists entirely of scheduled didactic activities and no scheduled patient care activities (for example, no care and treatment of individual patients, or no services which are billable) then, for documentation purposes, that workday must not be recorded as “patient care” (or, as occurring in a patient care unit such as ICU or Pediatrics, etc.).  Instead that workday must be identified as non-patient care and the time must be subtracted from the allowable FTE count (for IME if the training occurred within the hospital complex, and for both IME and direct GME if the training occurred in a non-hospital site).  In other words, as long as an entire workday is not scheduled for didactic activities, then for documentation purposes, that day may be recorded as spent in patient care activities.

CMS’ Example of the One Workday Standard

For example, if a hospital maintains rotation schedules in monthly blocks for each resident in a particular program, and if a resident that is otherwise assigned to the Coronary Care Unit (CCU) for the month of January was scheduled to attend an all day conference on January 10 and not to participate in any planned patient care activities on that day, then the hospital must note on the rotation schedule that it submits to the fiscal intermediary that this resident was not in “patient care” on January 10.  The hospital would subtract that time from the resident's allowable IME and/or direct GME FTE count accordingly.

Count Workdays Only Where There’s Documented Patient Care

As long as an entire workday is not scheduled for didactic activities, then for documentation purposes, that day may be recorded as spent in patient care activities. For all workdays counted, the hospital must be able to document that the resident was scheduled for at least some patient care activities. Of course, activities must be part of the approved residency training program in order to be counted for IME and direct GME payment purposes and a resident must be training within the hospital complex or in a non-hospital site. If a hospital documents that time was spent studying at a resident's or a teaching physician's home, this time is not permitted to be included in the IME count because it is not time spent in patient care, nor is it permitted to be included in the direct GME count because it did not take place in the hospital complex.

CMS’ Example of the One Workday Standard Revisited

Assuming the same facts utilized in CMS’s example, except, the resident is scheduled to attend a half day conference on January 10, and to participate in patient care activities the other half of the workday. In this case, the hospital would record January 10 as patient care and it would not be necessary to subtract that time from the residents’ allowable IME and/or direct GME FTE count.

Assistance

Should you have questions on this bulletin, please contact:

Western Pa Providers	Central & Eastern Pa. Providers	Maryland & District of Columbia Providers:
Drew Satriano Manager, Provider Audit (412) 544-1840	Leon Sokolosky Manager, Provider Audit (215) 654-5673	Adam Weber Manager, Provider Audit (410) 427-8726