Crystal's MCW Coder HubCan you even bill without the teaching physician being in the room with the resident?
Yes, there are two main instances where you can bill Medicare for services performed by a resident without the teaching physician being physically present in the exam room:
1. The Primary Care Exception
In specific primary care centers, residents can furnish lower-to-mid-level Evaluation and Management (E/M) services without the teaching physician’s physical presence during the exam.
- Requirements: The teaching physician must direct the care from a proximity, have no other responsibilities at the time, and review the medical record.
- Modifier: You must append Modifier -GE (Service performed by a resident without the presence of a teaching physician under the primary care exception) to the claim.
- Limitation: This applies only to specific codes (typically lower-level office visits) and specific residency programs.
2. Moonlighting
If the resident is fully licensed and working under a separate contract that is outside the scope of their approved Graduate Medical Education (GME) program, they are treated as an independent physician.
- Status: In this scenario, they are acting as an “attending” physician, not a trainee.
- Billing: You bill under the resident’s own NPI, and the Teaching Physician Guidelines (and supervision requirements) do not apply.
Here is a breakdown of the key rules and responsibilities for Teaching Physicians (TP) when billing Medicare for services involving residents, fellows, or students.
The Core Requirement: Physical Presence
To bill for a service performed by a resident, the Teaching Physician generally must be physically present during the “key or critical portions” of the service.
- Documentation: The TP cannot simply countersign a resident’s note. The record must document the TP’s physical presence and active participation in the management of the patient.
- “Review and Verify”: The TP is allowed to review and verify the resident’s note (history, exam, decision making) rather than re-documenting it, provided they add their own attestation of presence and agreement with the plan.
Service-Specific Rules
1. Evaluation & Management (E/M) Visits
- Selection by MDM: The TP can use the resident’s documentation of history, exam, and Medical Decision Making (MDM) to select the code level, provided the TP performed/verified the critical components.
- Selection by Time: If billing based on time, you generally cannot count time the resident spent alone with the patient. You may only count the time the TP spent personally (or present with the resident).
2. Procedures
- Minor (< 5 Minutes): The TP must be present for the entire procedure (e.g., simple sutures).
- Major (> 5 Minutes): The TP must be present for the key and critical portions and must be immediately available for the rest of the procedure.
3. Diagnostic Tests (Radiology/Pathology)
- Medicare pays for interpretations only if the TP personally reviews the image/specimen. If a resident drafts the report, the TP must document that they personally reviewed the image and agreed with or edited the findings.
4. Medical Students
- Students may document the history, exam, and MDM Tables in the chart.
- However, the TP must verify the documentation and personally perform (or re-perform) the physical exam and medical decision-making activities. The TP cannot just rely on the student’s exam findings.
Important Modifiers
- -GC: This service has been performed in part by a resident under the direction of a teaching physician. (Standard use).
- -GE: This service has been performed by a resident without the presence of a teaching physician under the Primary Care Exception (limited to specific primary care centers and lower-level codes).
Recent & Future Updates (2025/2026)
- Virtual Presence: Policies allowing teaching physicians to supervise residents virtually (audio/video) due to the PHE are generally set to expire. For CY 2026, CMS has proposed reinstating the requirement for in-person presence for teaching physicians in all teaching settings, with limited exceptions for rural areas.
The Core Requirement: Physical Presence
To bill for a service performed by a resident, the Teaching Physician generally must be physically present during the “key or critical portions” of the service.
- Documentation: The TP cannot simply countersign a resident’s note. The record must document the TP’s physical presence and active participation in the management of the patient.
- “Review and Verify”: The TP is allowed to review and verify the resident’s note (history, exam, decision making) rather than re-documenting it, provided they add their own attestation of presence and agreement with the plan.
Service-Specific Rules
1. Evaluation & Management (E/M) Visits
- Selection by MDM: The TP can use the resident’s documentation of history, exam, and Medical Decision Making (MDM) to select the code level, provided the TP performed/verified the critical components.
- Selection by Time: If billing based on time, you generally cannot count time the resident spent alone with the patient. You may only count the time the TP spent personally (or present with the resident).
2. Procedures
- Minor (< 5 Minutes): The TP must be present for the entire procedure (e.g., simple sutures).
- Major (> 5 Minutes): The TP must be present for the key and critical portions and must be immediately available for the rest of the procedure.
3. Diagnostic Tests (Radiology/Pathology)
- Medicare pays for interpretations only if the TP personally reviews the image/specimen. If a resident drafts the report, the TP must document that they personally reviewed the image and agreed with or edited the findings.
4. Medical Students
- Students may document the history, exam, and MDM in the chart.
- However, the TP must verify the documentation and personally perform (or re-perform) the physical exam and medical decision-making activities. The TP cannot just rely on the student’s exam findings.
Important Modifiers
- -GC: This service has been performed in part by a resident under the direction of a teaching physician. (Standard use).
- -GE: This service has been performed by a resident without the presence of a teaching physician under the Primary Care Exception (limited to specific primary care centers and lower-level codes).
When to Use Modifier GC
You must append this modifier to the procedure or E/M code in the following scenarios:
- Documentation Reliance: You used the resident’s (or fellow’s) notes to determine the level of service billed.
- Procedures: The teaching physician was physically present for the key or critical portions of the procedure and was immediately available for the remainder.
- E/M Visits: The teaching physician performed the service in part with the resident and utilized the resident’s documentation to support the claim.
When NOT to Use Modifier GC
- No Documentation: If the resident participated but did not document the service, or if you did not use their notes to generate the bill.
- Solo Performance: If the teaching physician performed the entire service personally without resident involvement.
- Primary Care Exception: If the service meets the specific “Primary Care Exception” rules (where the teaching physician isn’t required to be present), use Modifier GE instead.
Billing & Claims Tips
- Payment Impact: Modifier GC is informational only. It does not affect the reimbursement amount, but omitting it when a resident is involved is a compliance risk.
- Placement: Always list GC after payment modifiers (like -25, -57, or -RT/LT).
Recent & Future Updates (2025/2026)
- Virtual Presence: Policies allowing teaching physicians to supervise residents virtually (audio/video) due to the PHE are generally set to expire. For CY 2026, CMS has proposed reinstating the requirement for in-person presence for teaching physicians in all teaching settings, with limited exceptions for rural areas.
For Evaluation & Management (E/M) with a Resident
The most compliant attestations explicitly state that the TP saw the patient and performed the critical components of the visit.
- Sample 1 (Standard): “I, Dr. [Name], personally saw the patient, performed critical or key portions of the service, and discussed the care with the resident. I agree with the resident’s findings and plan as documented.”
- Sample 2 (Detailed): “Dr. [Name] performed a history and physical examination of the patient and discussed and agreed with the plan of care as described in the resident’s note above.”
Avoid This (Unacceptable): Do not use vague statements like “Agree with above,” “Rounded with resident,” or “Discussed with resident. Agree.” These do not prove your physical presence or personal performance of the service.
For Medical Students (Documentation Only)
If a medical student documented the note, the TP must verify the history and re-perform the physical exam and medical decision-making (MDM).
- Sample Attestation: “I, Dr. [Name], personally verified the history, examined the patient with the student, and performed the medical decision-making. I agree with the documentation and plan of care.”
For Procedures
- Minor (<5 mins): “I was present for the entire procedure.”
- Major (>5 mins): “I was present for the key and critical portions of the procedure [specify portions] and was immediately available for the duration of the procedure.”
Would you like to review the GC modifier requirements next to ensure these claims are flagged correctly in your billing system?