Wiki Clarification for 2023 time-based coding guidelines: Can we use resident time?

[SaraTrader]

Hello, I am in need of literature that supports resident time based coding. I attended a coding symposium this past week and someone mentioned that in the hospital inpatient setting, we can include the time the resident spent at bedside with the patient. Is this true? I am unable to find any literature that supports this- I am aware that residents cannot bill based on time in the office setting. Thanks!

 

[TThivierge]

• Hello SaraTrader.
• This should be written on end of progress notes done by resident once finished .It is proof attending doc guided him or her.
• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note. signed Dr Smith, MD then date and time. ” Use modifier GC for the resident if he treated pt. while attending doc supervised.; this go on claim. Then this statement must be on bottom of progress notes of the resident. Resident must sign too and date and time. Modifier GR is used if attending doing supervision and treating pt while resident watches or helps. But this attending doc must be filling that position. This data is found on the CMS web site and Hospitalist website as follows. Https://www.todayshospitalist.com/supervising-residents-heres-what-you-need-to-do-to-get-paid/ and https://www.cms.gov/Outreach-and-Ed.../Guidelines-Teaching-Physicians-Text-Only.pdf
• I hope this data helps you.
• Lady T