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. [...]