Question: One of our ED physicians and a resident performed a level-three ED E/M service for a 63-year-old patient with complaints of headache and dizziness, which was also the patient's final diagnosis. The patient was sent home with a prescription for Tylenol with codeine and instructed to check in with her primary care physician (PCP) should the headaches persist for more than four more days. Are we allowed to bill this visit under teaching physician (TP) rules? New Mexico Subscriber Answer: You'll have to go back and check the encounter notes to make sure the visit meets Medicare's TP reporting rules. If it does pass Medicare muster, you'd report the following: 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) appended to 99283 to show that you are billing the E/M under TP rules. 784.0 (Symptoms involving head and neck; headache) appended to 99283 to represent the 780.4 (Dizziness and giddiness) appended to 99283 to represent the patient's dizziness The catch: In order to bill under TP services, the physician must personally perform "critical and key portions" of the resident's E/M services. These critical or key portions are up to the TP, who might decide for one patient that the history and exam are critical and key portions. In the above example, the TP might decide that the HPI coupled with past medical history and physical exam did not warrant further diagnostic testing and were the key and critical portions of this service. Also, when you're billing an E/M under TP rules, the TP must document at least: Performance of the service or physical presence during the key or critical portions of the service when performed by a resident and TP The participation of the TP in the management of the patient. Don't sweat it: