Did you know that there are approximately 162,644 active medical residents and fellows in the U.S.? Among these, 82.3% are enrolled in specialty programs, and 17.7% are enrolled in subspecialty programs.
These residents are the future of the U.S. healthcare system. Acknowledging their crucial role, the Centers for Medicare and Medicaid (CMS) introduced special billing modifiers that identify the services performed by residents.
This guide will discuss one such two-digit code, i.e., the GE modifier. So, continue reading!
GE Modifier – Description
Modifier GE indicates that a care service was performed by a resident without the presence of a teaching physician (TP) under the primary care exception rule.
For context, Medicare’s primary care exception is a specialized billing rule. It enables a medical resident to perform and bill for low-to-moderate complexity evaluation and management (E/M) services without the presence of a teaching physician.
Scenarios Where a GE Modifier is Applicable
Let’s review a few real-world clinical scenarios where modifier GE applies:
Routine Follow-up for Hypertension
Picture a 62-year-old male established patient. He comes to a residency-based family medicine clinic for a routine blood pressure check-up.
At the facility, a second-year resident conducts the entire visit independently. That is, he adjusts the patient’s Lisinopril dosage based on the readings.
Immediately after the encounter, a teaching physician co-signs the resident’s notes after review, agreeing with the plan.
Here, you must report CPT code 99213 (established office visit, level 3) with the GE modifier. Why? Because the physician was not physically present during the key portion of the visit.
Initial Wellness Visit for a New Medicare Beneficiary
Assume a 66-year-old female patient who recently became a Medicare beneficiary visits an internal medicine teaching clinic for her initial preventive physical exam (IPPE).
A third-year resident performs the screening, reviews the medical history, and provides counseling on preventive services. Note that the teaching physician was in the building and was readily available, but did not enter the room. However, he later reviews the resident’s notes and documents his supervision.
Since the service falls under the allowed codes for the primary care exception, you should report HCPCS G0402 with the GE modifier.
Acute Sore Throat in a New Patient Evaluation
Imagine a 20-year-old male new patient who comes to a university health center, i.e., also an approved primary care site. He complains about experiencing a sore throat and fever for the past couple of days.
Thus, a resident notes down the history, performs a physician exam, and orders a rapid strep test. The result comes back negative. Hence, he diagnoses viral pharyngitis and recommends supportive care.
Here, the GE modifier applies to CPT 99202 (new patient office visit, level 2).
GE Modifier – Billing Guidelines
The following are some of the essential billing guidelines for modifier GE:
Understand When You Should Append It
Discussed below is the key criterion for using the GE modifier:
An Approved Setting
The resident performs care services independently in an approved primary care center. These include a hospital outpatient department or other ambulatory care center where the residency program is based.
Resident Experience
The resident who performs the service must have completed at least six months in an approved graduate medical education (GME) program.
Eligible Services
You can only append the GE modifier to primary care exception codes. These include the following:
- 99202, 99203 (New Patient E/M)
- 99211, 99212, 99213 (Established Patient E/M)
- G0402, G0438, G0439 (Medicare Wellness)
Teaching Physician Availability
Use it when the TP is not in the room. However, he should be in the same facility and readily available to assist if needed.
Know When NOT to Use the GE Modifier
Understanding when not to use modifier GE can help you avoid its misuse, limiting denials and audit risks:
- Note that you are only allowed to let a resident perform an entire service without TP’s supervision if it has low or mid-level complexity. That is, avoid using modifier GE for a high-level E/M visit.
- Do not try to bill a surgical or diagnostic procedure, like ultrasounds, with it.
- Modifier GE is not applicable if the resident has less than six months of training.
- The GE modifier is generally restricted to specialties such as OBGYN, family medicine, pediatrics, internal medicine, and geriatrics in primary care settings.
Fulfill Documentation Requirements
Detailed documentation is integral to justify the use of the GE modifier. Thus, include the following:
- Explain the extent of the TP’s participation in reviewing and directing the resident’s care.
- Explicitly state that the rendered service falls under the primary care exception rules.
- Confirm that the TP has reviewed the resident’s findings and agrees with the management plan.
- Remember that you can only document the E/M visits based on their medical decision-making complexity level.
GE vs GC Modifier: What’s the Difference?
The table below offers a glimpse into the key differences between the GE and GC modifiers:
| GE Modifier | GC Modifier | |
|---|---|---|
| Physician Presence | Not required. | Required. |
| Usage | Primary care residency clinics only. | Specialty care, high-level E/M, and surgeries. |
| Scope | Limited to low/mid-level E/M and wellness visit codes. | Applies to almost any billable service/procedure. |
| Documentation | The physician must document a review of the resident’s work and plan. | The physician must document his physical presence during the visit. |
Modifier GC indicates that a TP was involved in a service provided by a resident or was physically present for the key portion of the encounter.
Conversely, modifier GE explains that a resident saw a patient independently for low- to moderate-complexity visits. Besides, it also signals that the physician never entered the room during the encounter.
Summary
With that, it is time to conclude this guide. The GE modifier enables you to bill for the resident’s services provided during low-to-moderate complexity E/M and wellness visits.
However, you must not forget that the TP must be at the facility and readily available to assist. Besides, you can only append this modifier to primary care exception codes.Hopefully, these details will help you master billing for resident-performed services. However, if you struggle, feel free to outsource medical billing services to professionals like MediBillMD.
