Part B Insider (Multispecialty) Coding Alert

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 E/M service such as an outpatient service (99201-99205, 99211-99215) or an outpatient consul- tation (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 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 of Pennsylvania department of medicine in Philadelphia.

In other words, to support a 99202 claim, the physician would have to document an expanded problem-focused history, an expanded problem-focused exam, and straightforward medical decision-making, coding experts say.

Critical Care Requires Presence

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

Example: The physician 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 doctor):

- 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.

Surgical Claims Are Trickier

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

That means the physician must be present in the room. For example, your doctor can't view the session through a monitor in another room, Pohlig says.

Know Primary-Care Exception

If your physician is also a primary-care doctor 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. This 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, and 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, the MCM says.

To read more about the primary-care exception, visit the CMS Web site, and read the MLN product, -Guidelines for Teaching Physicians, Interns and Residents-at www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.