Gastroenterology Coding Alert

Question: A resident in our office sees a new patient complaining of heartburn. The resident conducts an expanded problem-focused history and exam and prescribes some antacids. All of this is documented in the resident's progress note. The gastroenterologist, who is working as a "teaching physician," also evaluates the patient, performs an exam, and consults with the patient on his condition. How should I report this encounter?

Montana Subscriber

Answer: On the claim, 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 decisionmaking), with 787.1 (Symptoms involving digestive system; heartburn). You should also attach modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) to 99202 to indicate that you are reporting a service under the teaching physician (TP) rules.

Remember: If the resident did not attend the TP's patient evaluation and also didn't perform a complete E/M service, the TP must bill and document the office visit as he would in a non-teaching setting.

Good practice: Because the TP's reimbursement now relies on the resident's documentation, the TP should ensure that the resident documents the appropriate history, exam, and medical decision-making elements.