ED Coding and Reimbursement Alert

Question: Do we need a GC modifier on our teaching physician claims?

Oklahoma Subscriber

Answer: The requirement for the resident to document a note is based on either or both of the following:

The institution where the services are being provided wants the resident to document in the medical record as part of the educational process or for medicolegal reasons.

The CPT^® codes assigned to the encounter will be based, in part, on the work and documentation of the resident.

If your facility requires documentation based on the first reason then the second reason is a moot point since there will always be resident notes. But if you are looking for a CMS requirement that the resident documents in the chart, then the second reason comes into play. And CMS only requires resident notes if they contribute to the code assigned to the encounter.

If the MD performs and documents all the elements of the service, even if the resident participated in the evaluation or did their own independent evaluation, you can base your coding on the MD notes only and the resident notes are not required.

CMS specifically lists this as a scenario in the manual. “The teaching physician personally performs all the required elements of an E/M service without a resident. In this scenario the resident may or may not have performed the E/M service independently.

In the absence of a note by a resident, the teaching physician must document as he/she would document an E/M service in a nonteaching setting.”

However, the absence of a resident note does not affect the use the GC modifier. Any involvement of a resident in the care of the patient must have a GC or GE modifier whether the resident did a note or not. Per CMS “Effective January 1, 1997, services furnished by teaching physicians involving a resident in the care of their patients must be identified as such on the claim”