Modifier Coding Alert

Published on Thu Dec 18, 2014 PDF

You might get paid even when your physician is not with her resident performing services.

Knowing how to apply modifiers GC (This service has been performed in part by a resident under the direction of a teaching physician) and GE (This service has been performed by a resident without the presence of a teaching physician under the primary care exception) are your keys to the success of showing the role of the resident and the attending physician. 

Read on to learn what CMS stipulations go along with the modifiers. 

Follow Requirements and Exceptions

You should use modifier GC when a resident performs a portion of a service in a teaching facility under the supervision of a teaching physician. Refer to chapter 12 of the Medicare Claims Processing Manual for the requirements.

Example: Your physician’s resident sees a patient under your physician’s supervision. The doctor is present in the room during the physical examination and medical decision making of the visit. “Modifier GC would apply in this situation,” says Candice Ruffing, CPC, CPMA, CPB, CENTC, at Acevedo Consulting Inc. in Delray Beach, Fla.

You would attach modifier GC to anything billable by a resident under a teaching physician, such as evaluation and management services or procedures like biopsies. 

CMS says that claims must include the GC modifier, “… for each service, unless the service is furnished under the primary care exception. When the GC modifier is included on a claim, you or another appropriate billing provider are certifying that you have complied with these requirements.” 

Beware: Your attending can’t just rely on the resident’s documentation. He must also write an attestation to indicate his involvement in the visit as well as his review and agreement to the resident’s note. The physician must also include a proper teaching physician attestation in the medical record. Examples of these can also be found in chapter 12.

Meet the Conditions and Use Modifier GE

If your teaching physician isn’t present when the resident performs a service with a patient, CMS may grant an exception allowing payment. Receiving the exception will depend on the level of service provided by the resident and the primary care facility has to follow a list of conditions and put in writing that they followed the conditions.

Exception: Payers may pay your teaching physician when she isn’t involved in the service such as when her resident sees his own patients in the clinic. Meeting the criteria set by CMS in their Exception for Evaluation and Management Services Furnished in Certain Primary Care Centers and including modifier GE on the claim, may allow your physician to receive payment for her residents’ work. 

“When the primary care exception applies, use modifier GE,” continues Ruffing. “The primary care exception says the teaching physician does not need to be present in certain situations when the resident provides a level-I, -II or -III service.” To be eligible for the exception, the resident or teaching physician must meet the following conditions:

1. The resident must complete at least six months of an approved GME residency program.
2. The teaching physician can supervise no more than four residents at a time.
3. The teaching physician must be immediately availability to the residents.
4. The teaching physician has to review the care given by the resident during or immediately after the service.
5. The teaching physician must document her review and her patient care direction.

The lower- and mid-level E/M services included in the exception are 99201-99203 (Office or other outpatient visit for the evaluation and management of a new patient, Â…) for a new patient and 99211-99213 (Office or other outpatient visit for the evaluation and management of an established patient, …) for an established patient.

Refer to the entire Guidelines for Teaching Physicians, Interns, and Residents at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/gdelinesteachgresfctsht.pdf 

to learn more about how to get the payment your office deserves.

Look Up Your Payers’ Guidance

Most payers may follow suit with CMS and require modifiers GC or GE when the criteria is met. Contact your payers to learn what you need to create an accurate claim. Here is a sampling of private payers’ preferences:

• Highmark Blue Shield says that when a physician directs an intern or resident, they pay the same as they would for the physician’s personal services when modifier GC is used.
• Palmetto GBA provides the following instructions for using modifier GC:

               “Submit this modifier with services that were performed by a resident in a teaching facility under the direction of a teaching physician.
              “This modifier is informational only and may be submitted with all HCPCS and CPT® codes.”

• Highmark Blue Shield in Pennsylvania and Cahaba GBA recognize modifier GC but they don’t provide any guidance for its use.