Medicare Compliance & Reimbursement

Here's which modifier to use for the primary-care exception You can ensure that your physician 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 physician 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. Experts offer field-tested strategies for reporting E/M services and minor surgical procedures using the teaching-physician rules. Code Based on 'Key Portions' Example: The TP provides 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, NM. How? If the resident also performed the E/M service the TP performed, your physician 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. The physician should report 99202 (Office or other outpatient visit for the E/M of a new patient) 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. Ensure Resident's Presence If the resident did not attend the TP's patient evaluation or did not perform the patient evaluation 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 [...]