Gastroenterology Coding Alert

Question: How should I code incident-to when our physician is in the office? What modifier should I use when our gastroenterologist is not in the office and the nurse practitioner (NP) sees a patient by herself?

Colorado Subscriber

Answer: Provider identification numbers (PINs), not modifiers, tell payers about an encounter's performer/supervisor. To indicate that the service meets Medicare's incident-to criteria, you should report the service using the gastroenterologist's PIN. The claim is blind as to whether an NP or physician performed the service, so payers reimburse the claim at 100 percent.

Remember: Incident-to implies that the NP provides the services under a physician's "direct supervision" following an established plan of care.

When an NP performs a service without the gastroenterologist's direct supervision, following an established treatment plan or evaluating a new problem or complaint, you should instead report the code under the NP's PIN. You should use the same procedure codes as with incident-to.

Caution: Before allowing your NP to provide services without direct supervision, make sure your state scope-of-practice and licensure laws permit doing so.

You might be confusing teaching facility supervision with physician supervision. In a teaching facility, you indicate the teaching physician's involvement with these modifiers:

• GC -- This service has been performed in part by a resident under the direction of a teaching physician

• GE -- This service has been performed by a resident without the presence of a teaching physician under the primary-care exception

• GR -- This service was provided in whole or in part by a resident in a Department of Veterans Affairs medical center or clinic, supervised in accordance with VA policy.

Example: Your gastroenterologist brought a resident from the hospital to see your patients in the office. The resident documented in patient charts, and your gastroenterologist signed off on the documentation. These claims must therefore have a modifier GC attached to them.

Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.