Modifier GC

Service has been performed in part by a resident under the direction of a teaching physician

Correct Use

  • Append to service that has been completed by a resident in a teaching facility in part under direction and supervision of a teaching physician
  • Append in second modifier field when supervising/teaching anesthesiologist is involved in two concurrent anesthesia cases with one resident (or "fellow"), he/she may bill usual base units and anesthesia time for amount of time present with resident throughout pre, intra and post anesthesia care.

Incorrect Use

  • Append to service when teaching physician is not involved with any part of care

Documentation

Notes recorded in the patient's medical records may be entered by a resident, teaching physician or nurse regarding the service furnished. Documentation may be dictated and typed or hand-written, or computer-generated and typed or handwritten. Documentation must be dated and include a legible signature or identity. Pursuant to 42 CFR 415.172 (b), documentation must identify, at a minimum, the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present.

Examples

  • Acceptable
    • Patient became hypoxic and hypotensive. I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs and oxygen. I reviewed the resident's assessment and plan of care.
  • Unacceptable
    • I saw the patient and agree with the resident.

Note: In a time based setting, such as critical care, time spent teaching does not count towards the critical care time of the physician; nor does the time the resident spent with the patient. Only time spent together with the patient or the teaching physician alone can be counted towards critical care time.

Resource

 

Last Updated Mon, 31 Oct 2022 18:51:25 +0000