GC, GE, and FS Modifier
GC Modifier
GC modifier is appended when resident is involved in patient care along with the billable providers, these billable providers are teaching physician
Resident (Fellow): A resident is a physician who has completed medical school and is undergoing specialized training in a particular field of medicine. He can render the service but cannot be billed independently. His service is billed for supervising or teaching physician. Where Teaching or supervising physician will attest the work resident.
Requirements of GC Modifier
Resident is involved in patient care.
Date and signed of the resident.
Attestation verbiage by teaching physician, it includes mainly 2 parts:
Agree with resident (his work or finding or similar verbiage) or corrected and updated as necessary.
Teaching physician should see the patient face to face.
Examples of attestation:
“I performed a history and physical exam of the patient and discussed his management with the resident. I reviewed the resident’s note and agreed with the documented findings and plan of care.”
“I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
“I saw and evaluated the patient. I reviewed the resident’s note and agreed with the findings and plan as documented in the resident’s note.”
“I saw and evaluated the patient. I reviewed the resident’s note and made corrections as necessary. I agree with the findings and plan of care as documented in the corrected note.”
GE Modifier
The GE modifier is used in medical coding to indicate that a service has been performed by a resident without the presence of a teaching physician under the primary care exception.
When a resident provides a service independently (without the direct supervision of a teaching physician), you would append the GE modifier to the relevant CPT code.
This modifier helps identify situations where the resident operates autonomously, typically in primary care settings.
FS Modifier
FS modifier is appended to denote the service is split or shared. A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed by both a physician and Non physician practitioner who are in the same group. When NPP and MD/DO are involved in patient's care and both are documenting their part then the service is considered as Split/Shared visit.
Whom payment would be made?
Service would be billed to that provider who has given the substantive portion of the report.
What is substantive portion?
Details about FS Modifier
Split and shared visits
Previously, CMS allowed NPP (such as a physician assistant, advanced practice registered nurse, nurse practitioner, clinical nurse specialist, or other nonphysician provider) and physicians who, worked for same facility (hospital) to share the patients visit on same day. This was done by billing their combined work under physician's NPI for 100% reimbursement. Even though, the NPP may have done the majority of work, the total pay were used to billed under physician's NPI. Later on, to increase the latitude of hospital and office e/m services, CMS introduced new instruction which came along with other condition, split and shared visit policy, allowance to NPPs to receive 85% of reimbursement using their own provider number and the ‘incedent to-’ concept.
The IOM of CMS defined split/shared visits as “a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”
Many updates came on later, the recent of which are the updates released in 2023 and 2024. Per the CMS statement “A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.”
Before 2023, the ‘substantive portion’ included one of the 3 key components of medical report (history, exam, or MDM) or more than half of the total time spent by the physician and NPP performing the split/shared visit. But since 2023, according to new guidance, the ‘substantive portion’ now will only be more than half the cumulative total time of the physician and NPP (This does not include critical care visits).
This type of visits are applicable for both: new and established patients, and in initial and subsequent visits and also in prolonged services (The new split/shared services apply only to services provided in hospital or SNF settings, no office visits).
To bill a split/shared e/m visit, either physician or NPP must have face-to-face contact with patient.
What does this mean??
It is not necessary that the one who is doing ‘substantive portion’ must have seen and/or evaluated the patient personally. The one who is doing other part, which is not substantive, can personally see and/or evaluate the patient. In simple words, it is not necessary that the ‘major work’ doing person must go and see or evaluate the patient. The ‘minor work’ doing person can do that too. What is necessary is either of them must give face-to-face time.
What is ‘Qualifying time and Distinct time’?
The time engaged in following activities can be used to score the total time for ‘substantive portion’ determination.
Preparing to see the patient (for example, review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)
either physician or NPP, anyone can perform this.
There are certain thinga they can't take as scoring point while determining the total time. They are:
The performance of other services that are reported separately
Travel
Teaching that is general and not limited to discussion that is required for the management of a specific patient.
When, the physician and NPP both meet or discuss the patient jointly, only one of them can use this distinct time to add to total time (only one can get credit of this joint time).
Finally, the AAPC reports that documentation under the 2024 split/shared services rules should identify both practitioners. However, the medical record should be signed and dated only by the billing practitioner.
Complying with 2024 split/shared services regulations, it is necessary to capture ‘appropriate documentation’ during patient's visit and MDM. The physician Vs NPP time must appropriately reported by documenting an individual note describing the portion of the service they performed. The documentation must ensure the time records don't show overlap between physician time and NPP time.
We will count only distinct time.
Example:
If a NPP first spent 10 min seeing the patient and physician then spent 15 min, then their individual time would sum up to total 25 min. The physician here would bill this visit as he spent more than than half of the total time. If, the physician and NPP meets together and spend 5 additional min on this patient to dicuss the treatment plan, this overlapping time of 5 min could only be counted once to establish total time and to decide who performed ‘substantive portion’ here. The total time will be 30 min and still the physician would bill this visit as he spent 20 min (20 out of 30 min) that is more than half of the total time spent.