Question:
Answer:
On the claim, 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 problemfocused examination; and straightforward medical decisionmaking), with 787.1 (Symptoms involving digestive system; heartburn). You should also attach modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) to 99202 to indicate that you are reporting a service under the teaching physician (TP) rules.Remember:
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.Good practice:
Because the TP's reimbursement now relies on the resident's documentation, the TP should ensure that the resident documents the appropriate history, exam, and medical decision-making elements.