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Modifier Coding Alert

Reader Question:

Include Modifier GC,Avert TP Coding Headaches

Question: What are the rules on teaching physicians (TP) being present during surgical procedures? Should we submit teaching physician claims with any modifiers?

Connecticut Subscriber

Answer: Whenever you code for a TP’s services, append modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) to show that the physician performed the procedure under TP guidelines. You also have to document that the attending or teaching physician was present during the encounter for the major parts of any procedure or encounter.

Payout: According to the Medicare Claims Processing Manual, Chapter 12, Section 100.1.2, carriers should only reimburse physician services for procedures when a teaching physician (TP) is present with the resident during the critical or key portions of the service.

A CMS transmittal, www.cms.hhs.gov/transmittals/downloads/R811CP.pdf  released back in 2006, clarified the definitions of “critical or key portion” and “physician presence” for the TP rules:

Critical or key portion: “That part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s). For purposes of this section, these terms are interchangeable.”

Physician presence: “The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.”

Experts suggest that for short procedures that cannot be divided into “critical” and “noncritical” components, the TP must be present for the entire procedure.

For longer and more major procedures, the TP must be in personal attendance only for those portions of the service deemed “critical” or “key” portions of the service. For the remaining portions of the service, the TP must remain immediately available, although not necessarily in the same room or area. The TP cannot be personally involved in a second surgery during the time of the first service because that might prevent him from being immediately available.