Crystal's MCW Coder Hub⚕️ Modifier GE - Resident Provided Service Without the Presence of a Teaching Physician Under the Primary Care Exception
Quick Reference
Descriptor: Resident provided service without the presence of a teaching physician under the primary care exception 1
Global Period: Follows the primary procedure code 2
Provider Type: Teaching Physician billing for services performed by a resident under Primary Care Exception (PCE) 3
Reimbursement: Medicare pays at 100% of the Physician Fee Schedule if PCE criteria are met 4
NCCI Status: Subject to Teaching Physician Guidelines and PCE rules 5
Approach: Appended to Evaluation and Management (E/M) CPT® codes
📋 Code Description & Clinical Context
Modifier -GE is a HCPCS Level II modifier used by a teaching physician to indicate that a service was performed by a resident without the physical presence of the teaching physician during the key portion(s) of the service, under the Primary Care Exception (PCE) 1. This exception allows teaching physicians to bill for certain low-complexity services provided by residents in outpatient clinics without meeting the standard physical presence requirements, provided specific criteria are met 3.
Key Usage Indications:
- Service is provided in an outpatient clinic setting (hospital outpatient departments generally excluded)
- Service is low complexity (typically CPT® 99202-99213)
- Teaching physician is immediately available to the resident during the service
- Teaching physician reviews the resident’s note and provides documentation of participation
- Service does not involve critical care or high-risk procedures
Primary Care Exception (PCE) Specificity
🌲 Code Hierarchy / Context
HCPCS Level II Modifiers
└─ Payment Modifiers
└─ Teaching Physician Modifiers
├─ -GC This service has been performed in part by a resident under the direction of a teaching physician
├─ -GE Resident provided service without the presence of a teaching physician under the primary care exception **← THIS CODE**
├─ -GR This service was performed in part by a resident in a department of veterans affairs medical center
└─ -QX CRNA service with medical direction by a physician
Parent Category: Teaching Physician Modifiers 6
Related Modifiers: -GC (Standard Teaching Physician), -GR (VA Medical Center), -QX (Anesthesia Direction)
Primary Code Dependency: Must be appended to a valid E/M CPT® code (e.g., 99213, 99214)
💰 Reimbursement & Valuation
| Component | Rate | Notes |
|---|---|---|
| Base Rate | 100% | Based on the allowed amount for the E/M CPT® code 4 |
| PCE Adjustment | None | Payment is not reduced if PCE criteria are fully met 4 |
| Non-Compliance | Denial | If PCE criteria are not met, claim may be denied or recouped 5 |
| Final -GE Rate | 100% | Of the total allowed physician fee schedule amount 4 |
| Global Period | Same as Primary | Follows the global days of the primary procedure (0, 10, or 90) 2 |
Assistant Surgeon Payable: N/A (Teaching Setting)
- Medicare Status Indicator: Depends on primary E/M code coverage 7
- If PCE requirements are not met, reimbursement may be denied
- Commercial payers may not recognize -GE; verify payer policy before billing
Medicare Payment Estimate: Varies by E/M level; calculated as Base Units × Conversion Factor 4
🚫 Includes / Excludes & NCCI Guidance
✅ Includes
- Services performed by a resident in an outpatient clinic setting
- Low complexity E/M services (typically 99202-99213)
- Teaching physician review and documentation of resident’s note
- Teaching physician availability during the service
- Services where physical presence is waived under PCE rules
❌ Excludes / Bundled Per NCCI
- Services performed by the teaching physician personally (no modifier needed or use -GC) 3
- High complexity E/M services (e.g., 99214, 99215) generally do not qualify for PCE 3
- Critical care services (e.g., 99291) 3
- Surgical procedures (PCE applies primarily to E/M) 3
- Services in hospital outpatient departments (PCE generally limited to clinics) 3
Teaching Physician Guidelines Critical Note:
🏥 MS-DRG Assignment (Inpatient Facility)
Modifier GE does not directly impact MS-DRG assignment, as DRGs are based on the primary procedure and diagnoses. It affects physician reimbursement under Medicare Part B.
| Scenario | Impact | Description |
|---|---|---|
| Outpatient Clinic E/M | Payment Allowed | Teaching physician paid at 100% if PCE met 4 |
| Inpatient Service | Not Applicable | PCE generally does not apply to inpatient services 3 |
| Inpatient Status | Part B Billing | Services billed on CMS-1500/837P 8 |
Note
Facility reimbursement (Part A) is not affected by modifier -GE; this modifier is for professional fee billing only 8.
🏷️ Common ICD-10-CM Diagnosis Codes
Modifier -GE does not change diagnosis coding requirements. Diagnosis codes must support the medical necessity of the E/M service.
Primary Diagnosis Options (Dependent on Visit)
| ICD-10-CM Code | Description | HCC Status* |
|---|---|---|
| E11.9 | Type 2 diabetes mellitus without complications | ✅ HCC (Diabetes) |
| I10 | Essential (primary) hypertension | ✅ HCC (Cardiovascular) |
| J44.9 | Chronic obstructive pulmonary disease, unspecified | ✅ HCC (Respiratory) |
| M17.11 | Unilateral primary osteoarthritis, right knee | ❌ Not HCC |
| F41.1 | Generalized anxiety disorder | ❌ Not HCC |
* HCC Status: Hierarchical Condition Category mapping for Medicare Advantage risk adjustment. Diagnosis codes determine HCC status, not the modifier. Modifier -GE has no impact on risk adjustment scores 910.
Supporting/Comorbid Codes (Document When Applicable)
- N18.30 Chronic kidney disease, stage 3 unspecified (HCC applicable)
- E66.01 Morbid (severe) obesity due to excess calories (HCC applicable)
- Z79.4 Long term (current) use of insulin (HCC applicable)
✏️ Modifiers Guidance
| Modifier | Use Case for GE | Payable? |
|---|---|---|
| -GC | Service performed in part by resident (Standard) | ❌ Do not use with -GE |
| -GR | Service performed in VA Medical Center | ❌ Mutually exclusive setting |
| -25 | Significant, Separately Identifiable E/M Service | ✅ Can be used with -GE on same day as procedure |
| -59 | Distinct Procedural Service | ✅ Can be used with -GE if distinct procedure performed |
| -95 | Synchronous Telemedicine Service | ✅ Can be used with -GE if PCE applies to telehealth |
| -24 | Unrelated E/M Service by Same Physician During Post-op Period | ✅ Can be used with -GE during global period |
📝 Coding Examples
✅ Example 1: Resident Provides Level 3 Visit Under PCE
Scenario: Resident sees established patient for HTN follow-up in outpatient clinic. Teaching physician is immediately available but not in room. Resident documents visit. Teaching physician reviews note and documents agreement.
Report:
❌ Example 2: High Complexity Visit Under PCE
Scenario: Resident sees patient for complex multi-system complaint (Level 5 visit). Teaching physician bills -GE.
Report: 99215--GE
Rationale: Incorrect. PCE generally applies only to low complexity visits (Level 1-3). High complexity visits require standard teaching physician presence (-GC) 3.
⚠️ Example 3: Missing Teaching Physician Documentation
Scenario: Resident documents visit. Teaching physician bills -GE but does not document their review/participation in the record.
Report: 99213--GE
Rationale: Incorrect. Teaching physician must document their participation (review/agreement) even under PCE. Claim may be denied 5.
✅ Example 4: E/M with Procedure on Same Day
Scenario: Patient sees resident for minor procedure (e.g., lesion removal) and significant E/M for separate problem. Teaching physician supervises under PCE for E/M.
Report:
🔍 Documentation Essentials for Support
To support modifier -GE and mitigate audit risk, medical documentation should include:
- Resident Note: Complete documentation by the resident performing the service 5.
- Teaching Physician Note: Statement indicating review and agreement (e.g., “Reviewed resident’s note, saw patient, agree with plan”) 5.
- Setting Confirmation: Documentation must reflect outpatient clinic setting (PCE eligible) 3.
- Availability: Record should reflect teaching physician was immediately available 3.
- Complexity: E/M level should align with PCE limits (typically low complexity) 3.
- Signature: Both resident and teaching physician must sign the record 5.
Medical Record Language
Ensure the teaching physician’s note states: “I reviewed the resident’s note, discussed the case with the resident, and agree with the findings and plan of care. I was immediately available during the service.”
⚠️ Common Pitfalls & Audit Risks
| Pitfall | Consequence | Prevention |
|---|---|---|
| Using -GE for high complexity E/M | Claim denial | Reserve -GE for low complexity visits (Level 1-3) 3 |
| Using -GE in hospital inpatient setting | Claim denial | PCE generally applies to outpatient clinics only 3 |
| Missing teaching physician signature | Payment denial | Ensure teaching physician signs the record 5 |
| Using -GE instead of -GC | Audit flag | Use -GC if teaching physician was present during key portions 3 |
| Commercial payer non-recognition | Claim denial | Verify commercial payer policy; many do not recognize GE 11 |
🔗 Related Codes & Crosswalks
| Code Type | Code | Relationship to GE |
|---|---|---|
| HCPCS Modifier | -GC | This service has been performed in part by a resident under the direction of a teaching physician |
| HCPCS Modifier | GR | This service was performed in part by a resident in a department of veterans affairs medical center |
| HCPCS Modifier | -25 | Significant, Separately Identifiable Evaluation and Management Service |
| CPT® | 99202-99213 | Office or Other Outpatient Services (Typical PCE codes) |
| CPT® | 99214-99215 | Higher Level E/M (Generally not PCE eligible) |
| CMS Form | CMS-1500 | Professional claim form where -GE is reported |
| CMS Pub | Pub 100-04 Ch 12 | Medicare Claims Processing Manual (Teaching Physicians) |
1 CMS HCPCS Level II Modifier Definitions
2 CMS Global Surgery Factsheet
3 Medicare Claims Processing Manual Ch. 12 (Teaching Physicians)
4 CMS Medicare Physician Fee Schedule 2024
5 CMS Teaching Physician Guidelines
6 NIH VSAC HCPCS Hierarchy
7 CMS MPFS Database Status Indicators
8 Medicare Claims Processing Manual Ch. 1
9 CMS-HCC Model V28 Documentation
10 Find-A-Code HCC Mapping Tool
11 AAPC Coding Modifier Guidelines
12 AAMC Teaching Physician Resources