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Cardiology Coding Alert

Take Steps to Reduce Denials for Teaching Physician Services

Published on Fri Jul 16, 2004

4 techniques can clarify confusing Medicare guidelines

When a cardiologist works as a "teaching physician" (TP) and supervises a resident's services in an office or a hospital setting, you will have to report the physician's work using the teaching physician rules, according to the Medicare Carriers Manual (MCM), section 15016.

Following the MCM guidelines for reporting TP services can trip up even the most seasoned coder. Read on for some expert advice for reporting E/M services and minor surgical procedures using the teaching physician rules.

Intern Must Be a GME Student

The MCM defines a resident as an intern or fellow who's enrolled in an accredited graduate medical education (GME) program, says Marti Geron, CPC, CMA, CM, coding and reimbursement manager at the University of Texas Southwestern Medical Center at Dallas.

Note: For more information on requirements for a resident to achieve fellow/intern status, see "You Be The Expert: TP Rules and Med Students".

1. Report Office Consults Based on 'Key Portions'

Let's say the TP provides an E/M service such as an office/other outpatient service (99201-99205, 99211-99215, or an office consultation 99241-99245) without the resident present. It may be possible to report under TP guidelines, experts say.

How? If the resident and the TP perform the E/M service, the TP would have to duplicate the "critical and key portions" of the resident's services to bill under this guideline.

Example: A resident sees a new patient complaining of chest pain when he breathes. The resident conducts an expanded problem-focused history and exam. The TP also evaluates the patient, performs an exam, and consults with the patient on his condition.

When filing this report, you should:

  • report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) to represent the office visit.
  • attach ICD-9 code 786.52 (Painful respiration) to 99202 to represent the patient's condition.
  • also attach modifier -GC (This service has been performed in part by a resident under the direction of a teaching physician) to 99202 to ensure that your Medicare carrier knows that you are reporting a service under the TP rules.

    The TP doesn't have to duplicate the resident's progress notes, Geron says. But the TP should refer to the resident's notes and state that the TP reviewed the resident's documentation and agrees with the diagnosis.

    Ensure Resident's Presence for Evaluations

    If the resident did not attend the TP's patient evaluation and also didn't perform a complete E/M service, the TP must bill and document the office visit as he would in a non-teaching setting, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

    In other words, to support a 99202 claim, the cardiologist would have to document:

  • an expanded, problem-focused history
  • an expanded, problem-focused exam
  • and straightforward medical decision-making.

    2. Document Cardiologist Presence for Critical Care

    You can also report under TP rules when the resident and TP perform critical care jointly. Suppose the cardiologist and the resident provide critical care treatment to a patient for a total of 56 minutes. Your physician may be able to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), as long as the documentation supports the code.

    Key questions: When filing TP claims involving critical care, make sure the cardiologist's supporting documentation points out that the TP (i.e., the cardiologist):

  • treated the patient jointly with the resident
  • directly supervised the resident for the full 54 minutes of treatment
  • directly managed the patient's care
  • referenced the resident's note in the documentation
  • noted a discussion with the resident concerning patient stabilization and patient consultation.

    3. Supervision Guides Surgical Procedure Claims

    When you report minor surgeries, you should make sure the cardiologist documents that he directly supervised the entire procedure. That means the physician must be present in the room.

    For example, your cardiologist can't view the session through a monitor in another room, Pohlig says.

    Example: The cardiologist supervises while the resident performs a thrombin injection with fluoroscopic guidance on a patient with a pseudoaneurysm. When filing this claim, you should:

  • report 36002 (Injection procedures [e.g., thrombin] for percutaneous treatment of extremity pseudoaneurysm) to represent the injection.
  • report 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) for the fluoroscopic guidance.
  • also include modifier -GC on the claim to show that the TPwas in attendance, though he didn't perform the procedure. (Make sure the documentation shows that the TPdirectly supervised the entire procedure.)

    4. Know How 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 direct supervision. These cases must fall under the Medicare Carrier Manual's primary-care exception, which refers to E/M new patient codes 99201-99203 and established patient codes 99211-99213.

    Remember: The primary-care exception applies only to primary-care practices. But the offices must be located in the outpatient department of a hospital or another ambulatory care entity, not a physician's office away from the center or during a home visit, the MCM states.

    To meet Medicare's documentation requirements for reporting 99201-99203 and 99211-99213 under the exception, make sure you can satisfy the following MCM criteria, which state that your teaching physician:

  • supervises no more than four residents at a time
  • is immediately available to help the resident maintain the primary medical responsibility for the patient's care
  • ensures that the resident provides reasonable and necessary services
  • reviews the care provided by the resident during or immediately following each E/M visit. (This review includes patient history, resident's findings on physical exam, diagnosis, and treatment plan. The TP must also document the extent of his participation in the review and direction of the patient care.)

    Remember: You should also attach modifier -GE (This service has been performed by a resident without the     presence of a teaching physician under the primary-care exception) to all services provided under the primary-care exception.

    Example: If you billed a level-two office visit of an established patient,

  • list 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making)
  • append modifier -GE to 99212 to show Medicare that the resident performed the service under the primary-care exception.

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