Pediatric Coding Alert

Techniques can clarify confusing Medicare guidelines

When a pediatrician works as a "teaching physician" (TP) and supervises a resident's services in an office or a hospital setting, you will have to report the 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 at Dallas.

Experts offer four field-tested strategies for reporting E/M services and minor surgical procedures using the teaching physician rules.

1. Report Office Consults Based on 'Key Portions'

Let's say the TP provides an E/M service such as an office/other outpatient service (99201-99205; 99211-99215, or an office consultation 99241-99245) without the resident present. It may be possible to report under TP guidelines, experts say.

How? If the resident and the TP perform the E/M service, the TP would have to duplicate the "critical and key portions" of the resident's services to bill under this guideline.

Example: A resident sees a 14-year-old new patient complaining of heartburn. The resident conducts an expanded problem-focused history and exam and prescribes some antacids. The TP also evaluates the patient, performs an exam, and consults with the patient on his 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 787.1 (Symptoms involving digestive system; heartburn) to represent the heartburn diagnosis.

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, Geron says. But the TP should refer to the resident's notes and state that the TP reviewed the resident's documentation and agrees with the diagnosis.

Ensure Resident's Presence for Evaluations

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 99202 claim, the pediatrician would have to document an expanded problem-focused history, an expanded problem-focused exam, and straightforward medical decision-making, coding experts say.

2. Document Pediatrician Presence for Critical Care

You can also report under TP rules when the resident and TP perform critical care jointly. Suppose the pediatrician and the resident treat an established 11-year-old patient having an anaphylactic reaction to a bee sting.

In tandem, the pediatrician and the resident provide a total of 54 minutes stabilizing the patient's respiratory distress, counseling the patient, and discussing the bee sting with the child's parents. 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 pediatrician's supporting documentation points out that the TP (i.e., the pediatrician):

treated the patient jointly with the resident

directly supervised the resident for the full 54 minutes of treatment

directly managed the patient's care

referenced the resident's note in the documentation

noted a discussion with the resident concerning the blood removal, patient stabilization and patient consultation.

3. Supervision Guides Surgical Procedure Claims

When you report minor surgeries and endoscopic procedures, you should make sure the pediatrician documents that he directly supervised the entire procedure. That means the physician must be present in the room.

For example, your pediatrician can't view the session through a monitor in another room, Pohlig says.

Medicare's clarification: The new teaching physician guidelines clarify what Medicare means by "physically present," says Jeff Linzer, MD, MICP, assistant professor of pediatrics at Emory University.

The TP's physical presence is now defined as "being present in the same room as the patient, or where face-to-face service is provided," Linzer says.

Example: Your pediatrician supervises while the resident performs a closed repair of a fractured wrist without manipulation. You should:

report 25600 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; without manipulation).

attach modifier -GC to 25600 to show that the TP was in attendance, though he didn't perform the procedure. (Make sure the documentation shows that the TP directly supervised the entire procedure.)

4. Know How to Use the Primary-Care Exception

In some cases, Medicare allows a TP to get paid when a resident provides an E/M service without the TP's direct supervision.

These cases 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. But 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 states.

To meet Medicare's documentation requirements for reporting 99201-99203 and 99211-99213 under the exception, make sure you can satisfy the following MCM criteria, which state that your teaching physician:

supervises no more than four residents at a time and is immediately available to help the resident maintain the primary medical responsibility for the patient's care

ensures that the resident provides reasonable and necessary services

reviews the care provided by the resident during or immediately following each E/M visit. (This review includes patient history, resident's findings on physical exam, diagnosis, and treatment plan. The TP must also document the extent of his participation in the review and direction of the patient care.)

Remember: You should also attach modifier -GE (This service has been performed by a resident without the presence of a teaching physician under the primary-care exception) to all services provided under the primary-care exception.

Example: If you billed a level-two office visit of an established patient, list 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) with modifier -GE attached to show Medicare that the resident performed the service under the primary-care exception.