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ED Coding and Reimbursement Alert

Modify the PATH to Proper Reimbursement With -GC

Published on Fri Nov 01, 2002

The straight and narrow path is the only way to appropriate reimbursement. ED coders in PATH (Physicians at Teaching Hospitals) settings must learn this maxim, or claims filed for services rendered by residents will encounter insurmountable obstacles.

The HHS Office of the Inspector General has stated that it will closely watch claims for teaching physicians, so it behooves you to pay special attention to Medicare rules. Published in September's issue of ED Coding Alert, "Coding Resident Services From Non-ED Specialties" offers expert advice on how to code properly for services rendered by residents in teaching-physician settings.

And this one additional tip could be the saving grace that keeps you from stumbling on the rough path toward Medicare compliance and reimbursement.

Appending Your Claims With Modifier -GC

When coding for Medicare Part B services, the physician must append modifier -GC (This service has been performed in part by a resident under the direction of a teaching physician) for every service involving a resident or fellow.

The Clinical Billing Services Compliance Office at Johns Hopkins University lists five scenarios requiring the application of modifier -GC when teaching physicians bill for services:

  • The TP's E/M documentation references the resident's documentation or verbal information. (Remember that the TP must perform the key portions of the history, physical exam and medical decision-making, but TPs can summarize the resident's documentation of past, family and social history, and review of systems.)
  • The TP is present for the entire minor procedure, including endoscopy that the resident performs. (A minor procedure takes fewer than five minutes.)
  • The TP is present during all critical portions of all surgical, high-risk and complex procedures (major procedures) that the resident performs. This includes procedures with a supervision and interpretation component, such as cardiovascular stress tests.
  • The TP reviews the resident's interpretation of slides, films and other test results.
  • The TP is present with the resident for anesthesia services during the induction, emergence and other key portions, and is available during the entire procedure.

    Note: Additional rules govern this scenario for two residents and for the team of both a resident and a CRNA.

    The compliance office also lists when modifier -GC is not needed:

  • The resident simply observes and doesn't contribute to the billed service.
  • The resident performs a part of the service that doesn't count as "involved" under PATH guidelines.

    Leah Galensen, billing coordinator at Rice Nephrology Associates in Chicago, offers a more lenient approach: You should append all claims for resident services with modifier -GC. In other words, don't err on the side of caution when applying it, but be sure the teaching-physician provisions are satisfied.

    If your secondary payer denies the claim when you add modifier -GC, ask for a written policy on teaching-physicians' services, Galensen adds. The carrier may require you to use chart notes or other documentation instead of modifier -GC, she says.

    When compiling documentation for modifier -GC, remember that the modifier should indicate that the TP was present during the crucial portion of the service involving the resident. The modifier should also help a payer track the documentation it requires from teaching physicians for reimbursement. Modifier -GC explains to payers why charts may involve two sets of information, the physician's and the resident's. Help the payers by making that division clearly visible.

    -GE Doesn't Apply

    Medicare lists two modifiers as teaching-physician modifiers: -GC and -GE. Modifier -GE, however, doesn't apply to the emergency department in a PATH setting.

    In an academic setting, the only codes that can be billed without the teaching physician present for the critical components of the visit are 99211-99213, codes that apply only to lower-level outpatient office visits for established patients. For these codes, you can add modifier -GE (This service has been performed by a resident without the presence of a teaching physician under the primary care exception), as outlined in Section 15016 of the Medicare Carriers Manual, for reimbursement.

    But codes 99211-99213 don't apply in the emergency department because of the "established" status of the patient, so modifier -GE is irrelevant.

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