Orthopedic Coding Alert

You can ensure that your orthopedic surgeon gets paid for E/M services and minor surgical procedures performed in a teaching setting, as long as you know the requirements for Medicare's teaching physician rules.

The lowdown: When your orthopedic surgeon 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 TP 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 these field-tested strategies for reporting E/M services and minor surgical procedures using the teaching physician rules.

Suppose the TP provides an E/M service such as an office visit (99201-99215) or an outpatient consultation (99241-99245) without the resident present. If the resident also performs the service, the TP may be able to take advantage of some of the resident's work under TP guidelines.

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. The TP should define -- and be able to defend -- those critical and key portions.

The TP's note can refer to the resident's notes and state that the TP reviewed the resident's medical documentation and agrees with the diagnosis. The TP doesn't have to duplicate the resident's progress notes.

Example: A resident sees an established patient who is complaining of wrist pain. The resident conducts an expanded problem-focused history and exam, and decides the patient requires strapping for a wrist sprain. 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 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision making of low complexity; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), with 29260 (Strapping; elbow or wrist) for the strapping. You should report the appropriate diagnosis, such as 842.00 (Sprains and strains of wrist and hand; wrist; unspecified site). You also may need to choose an E code to indicate the cause of the injury.

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 99213 to ensure that your Medicare carrier knows that you are reporting a service under the TP rules.

Sample payer guideline: Noridian, Part B carrier for many Western states, offers this instruction for established patient office visits: A "personal notation by the teaching physician must be entered highlighting two of the three key components of these services (e.g., history, physical examination and medical decision making)" (www.noridianmedicare.com/p-medb/enroll/general/teaching_physicians.html).

If the TP repeats "key elements of the service components obtained previously and documented by the resident (e.g., the patient's complete history and physical examination), the teaching physician need not repeat the documentation of these components in detail. Rather, the documentation of the teaching physician may be brief, summary comments that tie into the resident's entry and which confirm or revise the key elements. Therefore, the documentation of the key elements may be satisfied by the combination of entries into the medical records made by the resident and the teaching physician," Noridian's online policy states.

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, 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 99213 claim, the surgeon would have to document two of the three required components: an expanded problem-focused history, an expanded problem-focused exam and low-complexity medical decision making, coding experts say.

When you report minor surgeries, you should make sure you have documentation that the TP was present during all key or critical components. He also must be immediately available to furnish services during the procedure.

Example: Suppose your surgeon supervises the fellow during a superficial soft tissue biopsy of the upper arm (24065, Biopsy, soft tissue of upper arm or elbow area; superficial). Remember to append modifier GC to show that the TP was in attendance, although he didn't perform the procedure. (And make sure the documentation shows that the TP supervised the procedure, in accordance with your payer guidelines.)

Sample payer guideline: Noridian's TP policy states: "The teaching surgeon is responsible for the preoperative, operative and postoperative care of the beneficiary. The teaching surgeon may determine which post-operative visits are to be considered -key- and require his or her presence."

But Noridian also wants to know that the TP is immediately available to return to the procedure even during the period he doesn't have to be physically present. And if the TP "leaves the operating room after the key portion(s) of the surgical procedure or during the closing of the surgical field to become involved in another surgical procedure, he or she must arrange for another physician to be immediately available to intervene in the original case should the need arise, in order to bill for the original procedure."