ED Coding and Reimbursement Alert

Question: What are the documentation requirements when an attending physician supervises a resident in a teaching setting? For instance, does the history of present illness (HPI) or separately billable procedures need to be documented by the teaching physician for a claim to be submitted?

Texas Subscriber

 
Answer: Because the Office of the Inspector General (OIG) has stated it will closely watch areas like this for fraud and abuse, it is wise for supervising ED physicians to perform and document their own service in addition to the care provided by the resident. In other words, if a resident provides services to a patient independently, the teaching physician (TP) should repeat the key elements and bill according to the services documented. These elements can be discussed with the resident either before or after the teaching doctors personal service. The TP must indicate that he or she has read the residents notes and agrees. Then the TP must record information from each of the key elements (history, exam and decision-making) in the patients chart. This chart would be coded with the -GC modifier (this service has been performed in part by a resident under the direction of a teaching physician) added to indicate the involvement of a resident in the patients care. If a separately billable procedure is performed by the resident, the TPs involvement must be indicated by the attending physician in the patients chart.  
 
For minor procedures the TP must be present for the entire procedure and document that fact. For major procedures the TP must to be present for the key portions of the procedure. Medicare defines a major procedure as one that takes the resident more than four or five minutes to perform.
 
In an academic setting, the only codes that can be billed without the TP being physically present for the critical components of the visit are 99211-99213, which apply only to lower-level outpatient office visits for established patients. When this situation arises, the -GE modifier (this service has been performed by a resident without the presence of a teaching physician under the primary care exception) should be added. Codes 99211-99213 do not apply in the ED because of the established patient status, however.