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Hint: Mastering the primary care exception rule helps open reimbursement doors.

When your provider performs services as a teaching physician (TP), their coding may change quite a bit. A significant reason for that is the challenges inherent to supervising residents.

While TP services have been a longtime source of coding confusion, there鈥檚 one key tenet to follow. If you want to collect for the TP and resident鈥檚 services, then you鈥檒l need to use the following modifiers:

• Modifier GC (This service has been performed in part by a resident under the direction of a teaching physician)
• Modifier GE (This service has been performed by a resident without the presence of a teaching physician under the primary care exception)

Read on to discover what every practice must know about billing for TP and resident services.

Know Who Qualifies as a Resident

Not every medical student qualifies as a resident. Medicare and other insurers have very strict guidelines about which providers are classified as residents.

Part B Medicare Administrative Contractor (MAC) says: 鈥淎 resident is an individual who participates in an approved graduate medical education (GME) program. A student is an individual who participates in an accredited education program/medical school that is not an approved GME program.鈥� In its policy, which was updated in January 2024, Novitas clarifies that Medicare doesn鈥檛 cover services provided by students 鈥� only residents 鈥� and even residents鈥� services must fall under very specific guidelines.

A GME is a specific educational program that doctors participate in after receiving their medical degrees. These providers are out of medical school but are pursuing more real-world training by working directly with TPs and patients.

TP Supervises Resident? Look to Modifier GC

If the TP and resident see the patient together, but the resident performs part of the service, you should append modifier GC to the appropriate code. The TP must document that they either performed the service or were physically present during key or critical portions of the service. They should also record what their role was and what the resident did.

Example: A resident sees an established patient complaining of sinus pressure and pain. The resident conducts a thorough exam of the patient, takes their history, and diagnoses the patient with a sinus infection. All of this is documented in the resident鈥檚 progress note. The TP is present for the resident鈥檚 exam, and also evaluates the patient and discusses their condition. A prescription for antibiotics is digitally sent to the local pharmacy. Both providers document that 20 minutes were spent on the patient鈥檚 care.

The TP should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded) with modifier GC appended to it for this service.

Keep in mind that the TP doesn鈥檛 necessarily have to duplicate all of the resident鈥檚 progress notes. The TP鈥檚 documentation can refer to the resident鈥檚 notes and state that they were physically present for the visit, reviewed the resident鈥檚 medical documentation, and agree with the diagnosis and treatment plan.

Using the Primary Care Exception? Check Modifier GE

In some cases, Medicare allows a TP to get paid when a resident provides a low- or mid-level evaluation and management (E/M) service without the TP鈥檚 direct supervision. These cases must fall under Medicare鈥檚 primary care exception, which refers to E/M new patient codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) and 99203 (Office or other outpatient visit for the evaluation and management of a new patient 鈥� 30 minutes must be met or exceeded.) and established patient codes 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) through 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.). The TP doesn鈥檛 need to be present for the encounter, but they must review the care.

In addition to the E/M codes listed above, the initial preventive physical examination code G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) and the annual wellness visit codes G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) and G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit) can also be billed under the primary care exception, .

The clinic where the primary care exception services occur must be located in an outpatient department of the hospital or another ambulatory care entity that鈥檚 part of the GME program. Residency programs most likely to fall under the primary care exception are in the fields of family practice, pediatrics, ob-gyn, geriatric medicine, and internal medicine.

Important: Your residents may be trained on how to select the appropriate E/M level using either time or medical decision-making (MDM). However, when it comes to the primary care exception, only MDM applies. 鈥淯nder the primary care exception, you can鈥檛 use time to select visit level,鈥� .

Remember: Always append modifier GE to all services provided under the primary care exception.

For example, if you billed a level2 outpatient visit for an established patient, you would list 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.) with modifier GE attached to show Medicare that the resident performed the service under the primary care exception.

Torrey Kim, Contributing Writer, Raleigh, North Carolina