Techniques can clarify confusing Medicare guidelines When a physician 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. 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 TPrules. 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. 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 physician and the resident treat an established 11-year-old patient having an anaphylactic reaction to a bee sting. In tandem, the physician 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 physician's supporting documentation points out that the TP (i.e., the family practice physician): 3. Supervision Guides Surgical Procedure Claims When you report minor surgeries and endoscopic procedures, you should make sure the teaching physician documents that he directly supervised the entire procedure. That means the physician must be present in the room. 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 physician supervises while the resident performs a closed repair of a fractured wrist without manipulation. You should: 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. 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: 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.
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 ICD-9 787.1 (Symptoms involving digestive system; heartburn) to represent the heartburn diagnosis.
In other words, to support a 99202 claim, the teaching physician would have to document an expanded problem-focused history, an expanded problem-focused exam, and straightforward medical decision-making, coding experts say.
For example, your physician can't view the session through a monitor in another room, Pohlig says.
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.
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.