Otolaryngology Coding Alert

Prove ENT's presence and involvement with rock-solid -GC entries

You can ensure that your otolaryngologist's notes support his teaching-setting E/M services and minor procedures if you follow Medicare's teaching-physician documentation and supervision rules.

"Teaching facilities have come under the scrutiny of the Office of the Inspector General in recent years," says Victoria Menchaca, CCS-P, CPC, a reimbursement specialist in Los Alamitos, Calif. When your otolaryngologist works as a teaching physician (TP) and supervises a resident's services in an office or hospital setting, you have to report your physician's work using the teaching-physician rules.

Experts offer two field-tested strategies for reporting E/M services following TP guidelines. 

1. Code Resident-Only Services Using 'Key Portions'

When a resident provides an E/M service without a TP's presence, you can still report the service under TP guidelines. But the supervising otolaryngologist must duplicate the critical and key portions of the resident's service. "The TP must document that he personally provided the key portion of the service and reference the resident's note," says Bonnie Salvatore, CMA, CPC, CMC, CMOM, CMIS, a coding consultant and educator based in Stockbridge, Ga.

Example: A resident without the TP present sees a new patient whose mother says he has nasal discharge, cough and low-grade fever. The resident conducts an expanded problem-focused history and exam, and prescribes amoxicillin for the patient's upper respiratory infection (URI). The TP also evaluates the patient, performs an exam, and consults with the parent regarding the patient's 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), along with ICD-9 code 465.9 (Acute upper respiratory infection).

The TP doesn't have to duplicate the resident's progress notes, but should refer to the resident's notes and state that the TP reviewed the resident's medical documentation and agrees with the diagnosis. Proper documentation could state, "I saw and evaluated the patient. I reviewed Dr. Resident's note and agree with her assessment and plan, including the patient's acute URI necessitating antibiotic treatment."

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. The modifier tells the carrier that a resident performed part of the office visit service, Menchaca says. "The teaching physician can supervise up to four residents at any given time and must be immediately available (i.e, in the same office suite/floor)."

2. Apply Regular E/M Guidelines to TP-Alone Care

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.

Translation: To support a 99202 claim, the otolaryngologist would have to perform and document an expanded problem-focused history, an expanded problem-focused exam, and straightforward medical decision-making, coding experts say.