Coding Cues

December 1, 2006

If you're also teaching

When you work as a teaching physician (TP) and supervise a resident's services in your office or hospital setting, you'll have to report your work using the teaching physician rules. You can ensure that you get paid for E&M services and minor surgical procedures in a teaching setting if you know the documentation and supervision requirements.

Remember that Medicare defines a resident as an intern or fellow who's enrolled in an approved graduate medical education program, says Marti Geron, reimbursement and compliance manager at the University of Texas Southwestern Medical Center at Dallas.

Pay attention to a visit's 'key portions'

In other words, to support a 99203 claim, for instance, you'd have to make sure that you carry out and document a detailed history, a detailed examination, and low-complexity medical decision-making.

But if the resident performed the E&M service, you'd have to also perform the key or critical portions of the E&M. Or you'd have to be there when the resident performed them. You should document in your notes-and be able to defend-why you determined which aspects of the visit were the key or critical ones.

For example, a patient presents with high blood sugar (790.2x) and disorientation (780.4). You identify the physical examination as the visit's key portion. The resident evaluates the patient and diagnoses diabetes (250.xx). She recommends oral medication and a weight-reduction plan. You also evaluate the patient, perform an exam, and discuss possible diabetes management options with the patient. You can bill 99203.

Be sure to document that you performed the office visit's critical portion, and that you directly cared for the patient. You don't have to duplicate the resident's notes, but should refer to them, and state that you reviewed the resident's medical documentation and agree with the assessment and plan.

Don't forget to attach modifier –GC (this service has been performed in part by a resident under the direction of a teaching physician) to 99203 to ensure that your Medicare carrier knows that you're reporting a service under the teaching physician rules. (Use modifier –GR if you're in a VA facility.)

Know when to use the 'primary care exception'

In some cases, Medicare allows a TP to get paid when a resident provides an E&M service without the TP's personal involvement. These cases must fall under the "primary care exception," which includes new patient E&M codes 99201-99203, established patient codes 99211-99213, and G0344 (initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first 6 months of Medicare enrollment).

Primary care residency programs may qualify for this exception. The offices that provide services under the exception must be located in the outpatient department of a hospital or another ambulatory care entity. The services can't be performed in a physician's office away from the hospital or ambulatory care center or during a home visit.