99391 with GE Modifier

iceterrors

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Does anyone have experience with appending the GE modifier to CPT 99391? We're getting a lot of denials with our Medicaid payers and I can't find any information on whether or not this modifier is appropriate with this CPT code. I'm reviewing the coding for a teaching hospital and can't figure out why GE wouldn't apply..Thank you
 

iceterrors

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I'm really not sure - I'm in A/R recovery and work for a third party. I assume I need to find out if we are a primary care exception site? It's a very large teaching hospital if that helps..
 

SharonCollachi

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No, doesn't help. Here is the Medicare processing manual section, and usually Medicaid would follow Medicare although your state may have exceptions.

100.1.1 - Evaluation and Management (E/M) Services (Rev. 4283, Issued: 04-26-19, Effective: 01-01-19, Implementation: 07-29-19)

C. Exception for E/M Services Furnished in Certain Primary Care Centers

Teaching physicians providing E/M services with a GME program granted a primary care exception may bill Medicare for lower and mid-level E/M services provided by residents.

For the E/M codes listed below, teaching physicians may submit claims for services furnished by residents in the absence of a teaching physician:
99201, 99211, 99202, 99212, 99203, 99213

Effective January 1, 2005, the following code is included under the primary care exception: HCPCS code G0402 (Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first 12 months of Medicare enrollment).

Effective January 1, 2011, the following codes are included under the primary care exception: HCPCS codes G0438 (Annual wellness visit, including personal preventive plan service, first visit) and G0439 (Annual wellness visit, including personal preventive plan service, subsequent visit).

If a service other than those listed above needs to be furnished, then the general teaching physician policy set forth in §100.1 applies. For this exception to apply, a center must attest in writing that all the following conditions are met for a particular residency program. Prior approval is not necessary, but centers exercising the primary care exception must maintain records demonstrating that they qualify for the exception.

The services must be furnished in a center located in the outpatient department of a hospital or another ambulatory care entity in which the time spent by residents in patient care activities is included in determining direct GME payments to a teaching hospital by the hospital’s A/B MAC (A). This requirement is not met when the resident is assigned to a physician’s office away from the center or makes home visits. In the case of a nonhospital entity, verify with the A/B MAC (A) that the entity meets the requirements of a written agreement between the hospital and the entity set forth at 42 CFR 413.78(e)(3)(ii).

Under this exception, residents providing the billable patient care service without the physical presence of a teaching physician must have completed at least 6 months of a GME approved residency program. Centers must maintain information under the provisions at 42 CFR 413.79(a)(6).

Teaching physicians submitting claims under this exception may not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability. Teaching physicians may include residents with less than 6 months in a GME (Graduate Medical Education) approved residency program in the mix of four residents under the teaching physician’s supervision. However, the teaching physician must be physically present for the critical or key portions of services furnished by the residents with less than 6 months in a GME approved residency program. That is, the primary care exception does not apply in the case of residents with less than 6 months in a GME approved residency program.

Teaching physicians submitting claims under this exception must:
•Not have other responsibilities (including the supervision of other personnel) at the time the service was provided by the residents;​
•Have the primary medical responsibility for patients cared for by the residents;​
•Ensure that the care provided was reasonable and necessary;​
•Review the care provided by the residents during or immediately after each visit. This must include a review of the patient’s medical history, the resident’s findings on physical examination, the patient’s diagnosis, and treatment plan (i.e., record of tests and therapies); and​

Patients under this exception should consider the center to be their primary location for health care services. The residents must be expected to generally provide care to the same group of established patients during their residency training. The types of services furnished by residents under this exception include:
•Acute care for undifferentiated problems or chronic care for ongoing conditions including chronic mental illness;​
•Coordination of care furnished by other physicians and providers; and,​
•Comprehensive care not limited by organ system or diagnosis.​
Residency programs most likely qualifying for this exception include family practice, general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology.
Certain GME programs in psychiatry may qualify in special situations such as when the program furnishes comprehensive care for chronically mentally ill patients. These would be centers in which the range of services the residents are trained to furnish, and actually do furnish, include comprehensive medical care as well as psychiatric care. For example, antibiotics are being prescribed as well as psychotropic drugs.

The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.

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Novitas has a less-wordy explanation here:

Modifier GC
This service has been performed in part by a resident under the direction of a teaching physician.

Submit this modifier with services that were performed by a resident in a teaching facility under the direction of a teaching physician.

Modifier GE
This service has been performed by a resident without the presence of a teaching physician under the primary care exception.

Submit this modifier with services that were performed by a resident in a teaching facility without the presence of a teaching physician. This modifier is informational and may only be submitted with procedure codes:

HCPCS codes G0402, G0438 and G0439
CPT codes 99201 through 99203, and 99211 through 99213
CPT codes 93005 and 93041
Note: The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.

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Another good one here. This one is from an auditing company, and looks probably the most user-friendly of the three.
 

iceterrors

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Thank you so, so much. My apologies for how long it took me to circle back. So many other issues to deal with at the same time. I really appreciate your help!
 
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