Gastroenterology Coding Alert

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 a clinic 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 a resident 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 field field-tested strategies for reporting E/M services and minor surgical procedures using the teaching-physician rules.

The TP provides an E/M service such as an outpatient service (99201-99205, 99211-99215) or an outpatient consultation (99241-99245) without the resident present.

The TP may be able to use some of the resident's work under TP guidelines, says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M.

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

Example: A resident 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 TP also 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), with 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 TP rules.

"The TP doesn't have to duplicate the resident's progress notes, but in his own note he can refer to the resident's notes and state that the TP reviewed the resident's medical documentation and agrees with the diagnosis," Witt says.

If the resident did not attend the TP's patient evaluation or did not perform the patient evaluation in conjunction with the TP, the TP must perform, document and bill the office visit as he would in a nonteaching 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.

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

Example: 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 TP claims involving critical care, make sure the supporting documentation points out that the TP (the 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.

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

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 fellow 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 TP was in attendance, though he didn't perform the procedure. (Make sure the documentation shows that the TP directly supervised the entire procedure.)

If your gastroenterologist is also an internist and is treating a primary-care patient, you might be able to use the primary-care exception rule.

In a nutshell: In some cases, Medicare allows a TP to 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," Witt 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 TP must 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.