Primary Care Exception

Question: I work in a residency setting and we use the primary care exception rule that lets residents bill up to level three without attending physician presence. Two questions: 1) How do we bill inpatient services with the GE modifier using the exception, and 2) Can we use the exception on preventive services like 99397?

Answer: As to the inpatient service portion of your question, the exception rule states that "the services must be furnished in a primary-care center located in the outpatient department of a hospital or another ambulatory care entity." So no, there is no case where you would use GE for an inpatient service, only GC. If residents are involved in inpatient care, the attending must meet the presence requirements and document it. If a resident sees the patient without attending presence, it is not a billable service.

The second question involves preventive services. According to the CMS guidelines:

"Medicare may grant a primary care exception within an approved GME program in which the teaching physician is paid for certain E&M services the resident performs when the teaching physician is not present. The primary care exception applies to the following lower- and mid-level E&M services: 99201, 99202, 99203, 99211, 99212, 99213.

"Effective January 1, 2005, the following code is included under the primary exception: Healthcare Common Procedure Coding System code G3044: Initial Preventive Physical Examination: face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment."

The rules here pretty clearly define which codes can and can't be used. That last sentence says "code" - singular. I'm interpreting that to mean the other preventive service codes 99381-99397 are not eligible for the exception. That does not mean they can't be provided by a combination of resident and attending physicians and billed with a GC.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the January 2010 issue of Physicians Practice.