Ask the Expert

This month’s selection:

Let’s say a hospitalist does a face-to-face encounter and medically clears a patient for discharge on February 1. The patient is held over for three days awaiting a bed in a skilled nursing facility and physically leaves the facility on February 4. The hospitalist continues to see the patient until the 4th. What would be the proper way to code/bill for these services?

Scenario 1:
2/1 – 99238/9
2/2 – 99231
2/3 – 99231 (diagnostics are ordered/reviewed, patient given antibiotics)
2/4 – 99231

Scenario 2:
2/1 – 99238/9
2/2 – No billable charge based on medical necessity
2/3 – No billable charge based on medical necessity
2/4 – No billable charge based on medical necessity

Scenario 3:
2/1 – 99238/9
2/2 – No billable charge based on medical necessity
2/3 – 99232 (patient spikes a low-grade fever w/abd pain)
2/4 – No billable charge based on medical necessity

Are any of the following four scenarios billable under the teaching physician’s (TP) National Provider Identifier with the -GC modifier?

1. Resident and TP see the patient together. The resident completes the note, and the TP adds a macro statement, “I was personally present with the resident for the critical portions of the exam and medical decision making. I reviewed the documentation and agree with the resident’s plan of care.” The TP then electronically signs the note.
2. Same scenario as above, but the TP adds an addendum stating, “While examining the patient, they expressed a tingling sensation in both upper ext as well as neck pain. Based on my review of the CT scan completed earlier today, I will continue to hold the patient’s home meds. Spoke with Dr. A, Cardiologist, and she agreed to hold home meds. She will see the patient at some point today during her rounds. Placed order for cardiology and neurology consults.”
3. Resident sees the patient and completes the progress note. Later that same day, the TP has a face-to-face encounter with the patient and documents his own progress note, incorporating the resident’s note into his. The TP clearly documents his own A/P and adds a macro statement, “I have seen the patient independently and discussed the case with the resident.” TP electronically signs and dates the note.
4. Resident sees the patient and completes the progress note. He and the TP collaborate the following day and discuss the case. The TP adds a macro statement, “I reviewed the resident’s documentation and agree with the plan of care,” and the TP electronically signs and dates the note.

Deanna Anderson, CPC, CPMA, CEMC
Remote LRHPG Internal Profee E/M Auditor
LRH Physician Group Coding Department
Lakeland, Florida

Response:

Per the Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners, Section 30.6.1.B: “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code.”

In Scenario 2, the patient had already been discharged, and there is no medical necessity to support an E/M service on the subsequent dates. Therefore, these would be considered nonbillable encounters.

In Scenario 3, the patient's symptoms on February 3 do support medical necessity for a visit. However, as the patient had been discharged, reporting a subsequent inpatient E/M service (99232) would not be appropriate. Instead, the encounter could be billed using the appropriate outpatient E/M code (99212–99215), depending on the documentation and complexity of the service. Alternatively, if the physician determined that readmission was medically necessary, then the appropriate initial inpatient E/M code (99221–99223) could be reported.

Billing Under the Teaching Physician’s National Provider Identifier With Modifier -GC for Inpatient Hospital Setting
The CMS documentation requirements for teaching physicians were revised in 2023, resulting in less burdensome expectations compared with prior years. According to the Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners, Section 100.1.1.A:

“For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:

• that the teaching physician either personally performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
• the teaching physician’s participation in the management of the patient.

“The presence of the teaching physician during E/M services may be demonstrated through documentation in the medical record made by physicians, residents, or nurses.”

In summary, as long as the teaching physician either performs the service or is physically present during the key or critical portions, the resident, nurse, or teaching physician may document their participation.

In review of the scenarios provided:

• Scenarios 1 and 2 meet the requirements for reporting with the GC modifier, as they demonstrate the teaching physician’s presence during the key/critical portions.
• Scenarios 3 and 4 do not support use of the GC modifier, as there is no documentation of the teaching physician’s presence during the key/critical portions of the encounter.

— Ellen Hinkle, CPC, CPCO, CDEO, CPMA, CRC, CEMC, CFPC, CGSC, CIMC, COBGC, CPCD, CANCP, is an AAPC-approved instructor and AAPC National Advisory Board Member (2025–2027).