Medicare will pay physicians for procedures performed in teaching settings under the Medicare Physician Fee Schedule1. A teaching circumstance exists when a teaching physician involves a resident in the medical services rendered to a beneficiary2. Typically a claim would be filed under the physician’s name and National Provider Identifier (NPI) using the appropriate CPT/HCPS code plus the GC modifier. The GC modifier indicates, “This service has been performed in part by a resident under the direction of a teaching physician”3 and it certifies that the teaching physician met the performance requirement. In order for the coder to appropriately assign the GC modifier, the report must contain a number of key elements.
Teaching physician attestation
First and foremost the report must identify the teaching physician as he or she must perform the procedure or be present when the resident performs key or critical portions of the procedure. It is the NPI of the teaching physician that will be used to file the claim as payment is not made to the resident. The report will also identify the resident involved. The report can be prepared by either the teaching physician or the resident but the coder must be able to determine that the teaching physician performance requirement has been met. This is most commonly accomplished by use of a Teaching Physician Attestation (TPA). The TPA has different requirements depending on the type of procedure performed.
Diagnostic radiology TPA
For diagnostic radiology the teaching physician must read the study and either provide an interpretation or accept the interpretation provided by the resident with or without edit. A TPA for Diagnostic Radiology could simply state:
“I personally reviewed the images and agree with the interpretation of the resident.”
An unacceptable TPA would be one that simply countersigned or did not document performance such as:
“Agree with above” or “Discussed with resident”.
Interventional radiology TPA
Interventional radiology has a more complicated TPA as it potentially documents the teaching physician’s performance, supervision and availability. The teaching physician is required to be physically present in the procedure room for the key portions of a surgical procedure and immediately available to assist if not present for the whole procedure. For example, if the physician is not present for the whole procedure he or she cannot be performing the key portions of another procedure. For minor procedures Medicare requires the teaching physician to present for the entire procedure. Medicare defines a minor procedure as five minutes or less.
Examples of a TPA for interventional radiology would be:
“I was present for the entire procedure” or “I was present for the key portions of the procedure and immediately available to assist.”
Sometimes interventional and diagnostic radiology come together in one report such as diagnostic angiograms or imaging guidance. In these instances a combination of TPAs would be required:
“I was present for the entire procedure and I personally reviewed the images and agree with the interpretation of the resident.”
The signatures of both the teaching physician and the resident also provide critical information to the coder. The report should be signed by both the teaching physician (TP) and the resident. If the report is only signed by the TP it would be considered personally performed by the physician and the GC modifier would not be applied. If the report is signed only by the resident we would not be able to file a claim.
This article was intended to present the report requirements of the teaching physician and not all aspects of teaching physician billing were discussed. For more information on residents and teaching physicians please click here or see Guidelines for Teaching Physicians, Interns, and Residents on the CMS web site.