Part B Insider (Multispecialty) Coding Alert

Question: One of our physicians and a resident performed a levelthree emergency room E/M service for a 63-year-old patient with complaints of headache and dizziness, which was also the patient's final diagnosis. The patient was sent home with a prescription for Tylenol with codeine and instructed to check in with her primary care physician (PCP) should the headaches persist for more than four more days. Are we allowed to bill this visit under teaching physician (TP) rules?

New Mexico Subscriber

Answer: You'll have to go back and check the encounter notes to make sure the visit meets Medicare's TP reporting rules. If it does pass Medicare muster, you'd report the following:

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M
• Modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) appended to 99283 to show that you are billing the E/M under TP rules.
• 784.0 (Symptoms involving head and neck; headache) appended to 99283 to represent the
• 780.4 (Dizziness and giddiness) appended to 99283 to represent the patient's dizziness

The catch: The attending physician's actions, and the documentation, must meet Medicare's stringent rules, laid out in the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 100 as well as MCM Transmittals 1780 and 811. First, the MCPM defines a resident as an intern or fellow who's enrolled in an accredited graduate medical education (GME) program.

In order to bill under TP services, the physician must personally perform "critical and key portions" of the resident's E/M services. These critical or key portions are up to the TP, who might decide for one patient that the history and exam are critical and key portions.

In the above example, the TP might decide that the HPI coupled with past medical history and physical exam did not warrant further diagnostic testing and were the key and critical portions of this service.

Also, when you're billing an E/M under TP rules, the TP must document at least:

Performance of the service or physical presence during the key or critical portions of the service when performed by a resident and TP

The participation of the TP in the management of the patient.

Don't sweat it: The physician does not have to entirely record the full encounter; the TP's documentation can refer to the resident's notes and state that the TP agrees with the resident's assessments, medical documentation and diagnoses.