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Gastroenterology Coding Alert

4 Steps Reduce Denials for Teaching Physician Services

Published on Tue Jun 08, 2004

Use these techniques to clarify confusing Medicare guidelines

You can ensure that your gastroenterologist gets paid for E/M services and minor surgical procedures performed in a teaching setting -- if you know the documentation and supervision requirements for Medicare's teaching physician rules.

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

The MCM defines residents 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.

Experts offer 4 field-tested strategies for reporting E/M services and minor surgical procedures using the teaching physician rules.

1.Report Office Consults Based on 'Key Portions'

Let's say the TPprovides 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, said Jillian H. Kuruc, MHA, CPC, CCS-P, a clinical technical editor with Ingenix Health Intelligence in Binghamton, N.Y., during a session on the teaching physician rules at Ingenix's Third Annual Coding, Billing and Compliance Essentials Conference in Orlando.

How? If the resident also performed the E/M service the TPperformed, your gastroenterologist would have to duplicate the "critical and key portions" of the resident's services to bill under this guideline, Kuruc says. The TP should define -- and be able to defend -- those critical and key portions, she adds.

Example: Let's say a resident sees a new patient complaining of heartburn. The resident conducts an expanded problem-focused history and exam, and prescribes some antacids. The TPalso evaluates the patient, performs an exam, and consults with the patient on his condition.

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), along with ICD-9 code 787.1 (Symptoms involving digestive system; heartburn).

Tip: Don't forget to 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 teaching physician rules.

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

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 TPmust bill and document the office visit as he or she 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 gastroenterologist would have to document an expanded problem focused history, an expanded problem focused exam, and straightforward medical decision-making, coding experts say.

2.Document Gastro Presence for Critical Care

Documentation requirements for the claims are steep, but a gastroenterologist can also code when he and the resident perform critical care jointly, Kuruc says.

Example: Let's say the gastroenterologist and the resident treat a patient with severe gastrointestinal bleeding. They spend a total of 56 minutes of critical care time on the patient: 31 minutes to lavage excess blood, find the cause of the problem and stabilize the patient; and 25 minutes consulting with the patient and his wife.

In this case, 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 TPclaims involving critical care, make sure the supporting documentation points out that the TP(i.e. gastroenterologist):

  • treated the patient jointly with the resident.
  • directly supervised the resident for the full 56 minutes of treatment
  • directly managed the patient's care
  • referenced the resident's note in the documentation.
  • supervised the resident during the visit's history and exam
  • noted a discussion with the resident concerning the blood removal, patient stabilization and patient consultation.

    3.Supervision Guides Surgical Procedure Claims

    When you report minor surgeries and endoscopic procedures, you should make sure the gastroenterologist documents that he or she directly supervised the entire procedure, Kuruc says.

    That means the physician must be present in the room. For example, your gastroenterologist can't view the session through a monitor in another room, Pohlig says.

    Suppose your gastroenterologist supervises the resident during a colonoscopy with biopsy. Report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) with modifier -GC 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 TPto get paid when a resident provides an E/M service without the TP's direct supervision. These cases must fall under MCM's primary-care exception, which refers to E/M new patient codes 99201-99203 and established patient codes 99211-99213.

    The primary-care exception applies only to primary-care practices, Kuruc says. 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, according to the MCM.

    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 TP:

  • supervises no more than four residents at a time and 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 the patient's history, the resident's findings on physical examination, the diagnosis, and the treatment plan. Furthermore, the TPmust 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.

    For example, if you billed a level-two office visit of an established patient, you would 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) with modifier -GE attached to show Medicare that the resident performed the service under the primary-care exception.

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