Billing payers for services involving residents requires caution and consideration of Medicare rules. Such services have specific Medicare billing and documentation requirements. Billing professionals typically use the GE modifier to bill for such services.
Modifier GE indicates that a resident performed the service without the presence of a teaching physician under the primary care exception.
While the modifier seems straightforward on the surface, it can often lead to billing errors. The misuse of the modifier often leads to:
- Claim denials
- Delayed payments
- Compliance issues
GE Modifier – Description
According to the American Association of Professional Coders (AAPC), the GE modifier indicates:
A service performed by a resident without the presence of a teaching physician under the primary care exception.
Here, Medicare’s primary care exception is an applicable billing rule that allows a medical resident to perform and bill for particular services. The Medicare primary care exception permits certain evaluation and management (E/M) services furnished by residents in qualifying primary care settings.
However, the service should be provided without the teaching physician being physically present, provided all applicable Centers for Medicare and Medicaid Services (CMS) requirements are met.
Thus, the absence of a teaching physician is necessary for the GE modifier to be applicable. GE is frequently used in applicable scenarios, and residents play a vital role in today’s healthcare.
According to the Accreditation Council for Graduate Medical Education (ACGME), there are 162,644 active medical residents and fellows in the U.S. However, not every resident-performed service can be billed using the modifier. Thus, knowing specific cases where the modifier may apply matters.
Appropriate Use Cases for GE Modifier
The following are some billing-accurate use cases for GE:
Diabetes Follow-Up
Consider the case of a 58-year-old established male patient who visits a teaching clinic for a routine diabetes follow-up. For the service, a resident:
- Reviews the patient’s blood sugar readings
- Checks the current medications
- Makes a treatment adjustment
The teaching physician was not physically present for the encounter but met the applicable availability requirements under the primary care exception.
The resident documents the encounter, and the claim is reported with modifier GE when all applicable CMS requirements are met. After the services, the billing team uses the GE modifier to bill the payer.
Initial Medicare Preventive Visit
Imagine a 66-year-old woman, recently enrolled in Medicare, appears at a teaching clinic regarding an Initial Preventive Physical Examination (IPPE). During the IPPE, a resident:
- Reviews her history
- Completes the preventive assessment required
- Discusses recommended screenings
During the service, the teaching physician was not in the room. However, it is important to note that he was readily available and present in the building. Still, the resident’s documentation is reviewed by the teaching physician immediately after the visit.
Following the service, the GE modifier may be reported when IPPE and the teaching setting satisfy all applicable Medicare requirements.
Urinary Tract Infection
Consider the case of a 30-year-old new female patient. She visits a teaching clinic and complains of burning during urination and increased frequency. Therefore, a resident is assigned to:
- Take the patient’s history
- Perform the examination
- Review the test results
The test results indicate an uncomplicated UTI, and the service is complete while the teaching physician is not in the room. After the visit, the physician reviews the encounter although he is not physically present during it.
Notably, the teaching physician was immediately available, and the encounter otherwise satisfied the primary care exception. Therefore, the GE modifier was reported when billing the payer.
Accurate Usage Guidelines for GE Modifier
Seeking reimbursement for GE-related services with incomplete documentation or other billing violations leads to complications.
Billers who are unaware of the accurate usage guidelines for the modifier often face such errors. Therefore, here is what you should remember when billing for the modifier GE:
CMS Documentation and Eligibility
Meeting CMS’s documentation and eligibility standards is a must for the proper use of the GE modifier. Without it, no GE claim can be processed or reimbursed accurately. According to the latest requirements:
The service must be furnished in a setting that meets CMS requirements for the primary care exception, and the resident, teaching physician, program, and service must satisfy the applicable eligibility criteria.
Primary Care Exception
As mentioned earlier, GE applies only to specific situations. Therefore, billing consistency is just as crucial as eligibility.
Billing teams should append the GE modifier only to qualifying services furnished under the primary care exception and reported in accordance with applicable CMS requirements.
Documentation and Attestation
The attestation of the submitted documentation is also a central requirement for accurate billing. CMS’s ‘Exception for E/M Services Furnished in Certain Primary Care Centers’ discusses the requirements in detail.
Teaching practices must maintain the documentation and attestations required under applicable CMS and Medicare Administrative Contractor (MAC) requirements. Billing teams should verify any enrollment, certification, or attestation requirements with the applicable MAC.
Payer-Specific Requirements
In addition to the crucial requirements, practices should also stay alert to payer-specific alignment. Payer-specific requirements are always subject to change and may lead to billing errors if violated.
For instance, some commercial payers, including UnitedHealthcare under its applicable policy, may apply requirements similar to CMS’s primary care exception.
Important Billing Insight: Practices should verify the specific payer’s current policy rather than assuming Medicare rules apply universally.
Summary of the GE Modifier
The GE modifier is a specific yet important modifier used in teaching-hospital billing. For Medicare claims, GE identifies qualifying services furnished by a resident under the primary care exception when the applicable CMS requirements are satisfied.
Most new billers assume GE billing is simple and requires no extra effort. However, this couldn’t be further from the truth. Billing for GE requires understanding:
- Site eligibility
- Correct code selection
- Thorough attestation
Missing these requirements can result in claim delays, rejections, payment issues, or increased compliance risk.
Misusing GE can lead to denials, which is why teaching practices should always have billing staff specialized in GE billing.
If your in-house teams are having trouble billing the GE modifier, NeuraBill’s medical billing and coding services can help. Our qualified team ensures all claims are accurate and have a lower risk of denial across teaching physician claims.
