Debi Behunin
Share:
Our webinar on 2023 Coding Changes raised a lot of questions! We wanted to make sure that we answered each and every one, so we created this eBrief with our responses to your questions.
Q: What if more than one type of specialist sees the patient for a consultation during the same hospital stay?
A: Each specialty/subspecialty can bill an initial consultant during the same hospital stay.
Q: To clarify this from the slide: "Critical care can be billed on same day as ER services if after ER services when the patient's condition changes." My question is – if Provider A sees the patient first in the ED, then the Provider B sees the patient as continuation of service and when Provider B is seeing the patient, the patient's condition deteriorates and Provider B documents critical care on progress note. In this scenario, do we bill both 99281 series for Provider A and 99291 series for Provider B? OR do we just bill 99291 under Provider B?
A: “Critical care and emergency department services may both be reported on the same day when after completion of the emergency department service, the condition of the patient changes and critical care services are provided” (AMA 2023 E/M Coding Guidelines). Therefore, you can bill 99281 for Provider A and 99291 for Provider B.
Q: I have a question which is slightly out of the slides. I would really appreciate it if I could get the answer to this scenario: Patient is seen in ED and Provider A documents Critical Care and admits the patient. Now, the hospital also bills Critical Care on same DOS. In this scenario, can ED bill the critical care code? Note: As per MUE only 1 unit is allowed per DOS.
A: The situation you describe is really two billing issues: 1) what is billable by the physician for professional services, 2) what is billable by the facility for services rendered by the institution. Each of these providers can bill Critical Care on the same DOS. The MUE applies to each physician or the facility billing multiple of the same codes on the same date of service. If the institution is billing both components, the revenue codes will distinguish these services.
Q: A hospitalist sees a patient in the ER at 11:45 pm and decides to admit. The hospital shows the admit date as the next day. Does the hospitalist bill an admit or an outpatient code?
A: The hospitalist would bill an admit code.
Q: Since ALF codes will be deleted, should ALF providers use Home or ALF place of service?
A: Yes, codes 99341 - 99345 should be used for Assisted Living Facilities.
Q: So that I'm clear, are pre-authorization forms no longer needed with claims as of January? Is this proposed or will it actually happen?
A: Pre-authorization for specific DME codes IS being stopped 1/1/2023 for the following procedures:
-
- Oxygen
- Pneumatic Compression Devices
- Osteogenesis Stimulators
- Transcutaneous Electrical Nerve Stimulator
- Seat Lift Mechanisms
- External Infusion Pumps
- Enteral and Parenteral Nutrition
Other procedures still require pre-authorization. This is a proposed change. Final changes will be published later this year.
Q: What about sub-specialties within the same practice – for example Cardiology, Electrophysiology, Cardiac Surgery – would this fall under the sub-specialty rule?
A: Yes, each cardiac sub-specialty within the same practice can be an initial visit code.
Q: Medicare does not cover the consultation codes currently. Is that still correct? Or did I miss something?
A: There are no indications that this is changing in 2023.
Q: Is the CPT rule of billing same day earlier E/M in office and inpatient admission with modifier 25 allowed by Medicare? Did CMS adopt this CPT rule as well?
A: CMS did not specify whether or not they are adopting this portion of the E/M guidelines.
They stated: "Similar to the approach we finalized in the CY 2021 PFS final rule for office/outpatient E/M visit coding and documentation, we are proposing to adopt most of these changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) effective January 1, 2023. This revised coding and documentation framework would include CPT code definition changes (revisions to the Other E/M code descriptors), including: New descriptor times (where relevant); Revised interpretive guidelines for levels of medical decision making; Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services); Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam). We are proposing to maintain the current billing policies that apply to the E/Ms while we consider potential revisions that might be necessary in future rulemaking. We are also proposing to create Medicare-specific coding for payment of Other E/M prolonged services, similar to what CMS adopted in CY 2021 for payment of Office/Outpatient prolonged services."
We suggest looking for clarification when CMS publishes their final rule late in 2022.
Q: What about sub-specialties in Ophthalmology in a group practice with a shared chart?
A: Based on the AMA guidelines, different sub-specialties within Ophthalmology can bill initial visits. A shared chart is not a factor when billing initial visits within the same group or practice.
Q: Do you put Modifier 25 on the office visit?
A: Modifier 25 would be put on the second E/M performed in the same day.
Q: If it's an NP and a Psych NP, can they bill new patient?
A: Assuming the NP does not have a specialty of psych, they can both bill new patient visits.
Q: Do the new E/M changes apply to Rural Health Care Clinics?
A: Yes, FQHC are included in the current comment period for these guidelines. https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center
Q: What criteria would apply for Oncology with subspecialties, i.e. Radiation, Medical Oncology, Surgical Oncology, etc.?
A: Each subspecialty (Radiation, Medical, Surgical) can bill an initial visit.
Q: Patient was admitted in OBS and the admitting physician billed for initial observation code, then the next day patient admitted as inpatient. Are we supposed to do a charge correction to change the initial observation code to inpatient code?
A: No, it is not necessary to change the billing for observation. The only requirement is to bill the inpatient with a subsequent visit code.
Q: What if one is General Ortho and one is an Ortho Hand Surgeon. Could they both bill new?
A: Yes, because they have different subspecialties.
Q: The dental services would be covered if it relates to cardiac issues, correct?
A: Yes, in SOME circumstances. "Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. Such examination would be covered under Part A if performed by a dentist on the hospital's staff or under Part B if performed by a physician." https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage
Q: When our surgeons are on ER call and are called to see a patient at the hospital (usually in the ER) for surgical consult, can we bill the out-patient consult code? What place of service is used? The ER or out-patient hospital?
A: Yes, you would bill an outpatient consultation code if the consultation took place in the ER. Place of service would be 23 emergency department in a hospital.
Q: Can you clarify if the two-digit Specialty Codes are used to identify the physician as being in the same subspecialty based on the enrollment of the physician with NPPES. Example is: an Orthopedic surgeon and an Orthopedic hand surgeon that are both mapped to specialty code 20 based on the Taxonomy, wouldn't they be considered the same specialty for Medicare?
A: There are no directions as to how to determine subspecialties from either CMS or the AMA. The two-digit codes do not contain a comprehensive list of specialties and sub-specialties. We would recommend using the taxonomy codes to determine if there are recognized subspecialties. The taxonomy codes are different for orthopedic surgery and orthopedic hand surgeon, therefore, they are different subspecialties.
Q: For the cardio subspecialty question as they can be billed separately. Would you consider differentiating this E/M billing by adding modifier 25 as majority of payers deny such separate cardiothoracic, EP, interventional cardio services as they don't recognize subspecialty within cardio?
A: Yes, adding modifier 25 would appropriately indicate this is a separate service.
Q: In 2023, how will shared visits be leveled? Is it still by substantial portion of ANY of the three elements or time? Or can only MDM or time be used to level?
A: CMS is delaying the adoption of Shared/Split services.
Until 2024, CMS states "Under our proposal, clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion, until CY 2024." https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule
Q: What about consultations within the same group practices if a consulting provider has more expertise in a specific medical area?
A: Multiple providers in the same group can bill an initial consultation IF they have different subspecialties. If the providers are of the same specialty, even though one has more expertise, they cannot both bill initial consultations.
Q: Does Medicare still NOT pay for/use consultation codes?
A: Correct, CMS does not pay for/use the CPT consultation codes. CMS has not announced any plans to change this practice.
Q: Can 99358 be used to review documents/history of a client that you will be seeing for an intake psychiatry assessment the next day?
A: Yes, these codes can be used before or after the E/M service.
Q: Is there a code to bill for admitted patients that are 'boarded' in the ER for several hours or days waiting on an in-patient bed to become available? The ER staff is still providing care and resources for these patients.
A: This appears to be a situation for using 99281 as care is being provided by clinical staff.
Q: Is the delay on the S/S finalized by CMS? I knew it was under proposal.
A: Yes, it has been delayed.
Q: If seen in clinic by a urology provider and then seen later that day by another urology provider (both providers are in the same department) and admitted. Can we bill the office visit and the admission code on the same day?
A: Yes, you would bill the outpatient visit and an inpatient visit on the same day. Modifier needs to be assigned to the inpatient visit.
Q: What is not separately reportable? I did not hear the word.
A: Pulse Oximetry or "Pulse Ox" cannot be billed separately even it though there is separate code for this procedure.
Q: Can a provider bill a 99211 for services provided by nursing/ancillary staff as well as a 99214 for the same visit? I assume both can be billed if the MD does a telehealth visit and then instructs the patient to go to the office and see the nurse for a vaccine, but I'm anticipating our providers billing both for an in-office visit.
A: Yes, the 99214 could be billed by the physician. The correct code to be billed for the vaccine administered by the nurse would be 99211. The physician should not bill a second office visit because they did not see the patient when they came to the office visit.
Q: If billing on total time and an EKG is performed, can you count the total time and not bill for the EKG if the provider forgot to carve out the EKG time performing and documenting?
A: While we believe this is not the intent of the guidelines, we think method is not technically incorrect.
Q: Can you clarify prolonged with ER visits? It was my understanding you cannot bill based on time with ER codes.
A: You are correct, they are only MDM.
Q: The patient presents to the ER and is triaged and sent to wait in the waiting room because there were no beds available. Patient was called back for a CT of the brain, but after this imaging, she was sent back to the waiting room. Patient left without being seen by a physician or PA/NP. Besides billing the CT, what other services should be billed to the patient? This is a 2022 scenario.
A: It does not seem like any service was rendered by the ER's clinical staff so nothing else should be billed.
Q: Do these updates affect the FACILITY E/M level?
A: The guidelines are specifically published for professional services. Typically, facility billing follows, however, neither the American Hospital Association (AHA) or CMS have addressed this issue.
Q: If the visit is for scheduled testing (ULS/Labs) only and the Ultrasound and labs are separately billed, should a separate E/M (99213) also be billed when any changes to the plan of care use the results of those tests? MDM is based upon those results only. (Infertility specialty). Sometimes the patient leaves the office before the MDM takes place and receives a call later in the day with next steps. Many thanks for any input into this pattern.
A: An E/M can only be billed if there is face-to-face contact. If the call later in the day includes face-to-face and meets telehealth guidelines, then an E/M could be billed.
Q: I use content in the CC/HPI to determine level of service also because sometimes what is in Assessment and Plan are not adequate?
A: Using content in the CC/HPI to determine level of service is correct.
Q: Does the 99358 prolong service code qualify for the halfway point of 16 minutes to bill?
A: Yes.
Q: If a patient is seen in a primary care setting and then goes to urgent care (and maybe vice versa) under the same umbrella/physician group in a health system, would that be a new patient or established patient?
A: Assuming both providers are of the same specialty and subspecialty, whomever performed the initial E/M would bill the initial visit. The second provider would bill an established visit with modifier 25.
Q: Can you give an example of a specialty/subspecialty? Also, if a clinic is part of an FQHC, these wouldn’t apply, correct?
A: Obstetrician and maternal fetal medicine. Cardiologist and Pediatric Cardiologist. See response to the other questions for additional examples.
Q: I read from the AAPC that 99418 will be available for inpatient/observation instead of the 993X0. Have you seen anything from AMA?
A: No, there is no documentation in the AMA's 2023 E/M guidelines regarding 99418.
Q: Please confirm the changes are applicable to FQHCs.
A: Yes, FQHC are included in the current comment period for these guidelines. https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center
Q: With the changes to 99281, if the physician is covering a call at the ED and is signing off on the ED visits, but the clinical staff is not employed by our organization – can it still be billed for our provider?
A: No, unless the provider is paying the staff, they cannot bill for their services.
Q: Who is "they" that the presenter is referring to?
A: Usually the AMA who published the new E/M guidelines.
Q: Our providers just became the medical primary care for SNF/SN/LTC – so we cannot bill initial care to each of these patients as we have never seen them?
A: Initial visits can be billed if the provider has not seen the patient before in the facility.
Q: On the consultation codes are they always billed on time? If my provider is billing a consultation time, should he be documenting time spent on that visit for it to count? If he does not, does it then need to be billed as a new patient E/M?
A: Consultations can be billed using MDM or time.
Q: That explanation doesn't make sense. Are you saying that consult in-office then consult to inpatient can both be billed?
A: The scenario you describe can be billed IF the providers have different specialties or subspecialties.
Q: In the event that a consultation was performed during a home/residence visit – what would be the correct code set to use if this patient had a Medicare payer?
A: Final guidelines from CMS have not been published, but as of now it appears Medicare will NOT be recognizing the consult codes.
Q: Will telehealth for physical health not be allowed after the PHE 151 day grace period? What about video? I understand the changes in behavioral health in CAA.
A: No final decision has been made.
Q: Can a lab order be counted on data tab if office bills for the code in POS 11? How will lab/test orders work in inpatient services?
A: No, it cannot be considered when determining the level of service if the provider is billing for the service. Inpatient services are typically billed by the facility, hence, most of the time the provider includes time spent analyzing tests/data when the select the level of E/M.
Q: Are breast surgeons and general surgeons the same specialty?
A: They are different sub-specialties.
Q: These Certificates of Medical Necessity, are the same as pre-authorization?
A: Yes, but specific to DME.
Q: So, the prolonged visit codes for inpatients apply only to the higher level initial and subsequent visits, like the office/outpatient series 99205/99215? Is this correct?
A: Yes, there is a basic assumption that the highest level of E/M would be billed for the visit portion before it is appropriate to use prolonged codes.
Q: If a patient is seen in the ER not as a convenience, can any provider bill an ER code, or are ER codes only for ED physicians' use?
A: Yes.
Q: As far as E/M coding in the emergency department, I know the new rules will be applicable for the physician but what about the facility side of E/M assignment? We currently base our facility E/M on nursing intervention.
A: The guidelines are specifically published for professional services. Typically, facility billing follows, however, neither the American Hospital Association (AHA) or CMS have addressed this issue.
Q: 99288: Can it be used in the direction of the EMS personnel when they call the ED for guidance in addition to the ED E/M 99281-99285?
A: Yes.
Q: Aren't consultations not recognized by Medicare and most other payors?
A: You are correct, CMS does not recognize consult codes.
Q: Since the proposed rule of delaying time for shared visits, is it recommended to go back to using MDM? Or is finishing out the year with time okay until we get the final rule?
A: CMS is delaying the adoption of Shared/Split services.
Until 2024, CMS states "Under our proposal, clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion, until CY 2024." https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule
Q: Will there be different codes for Medicare prolonged (G2212) and CPT like the outpatient codes?
A: CMS is proposing HCPCS codes for prolonged services but have not published final rules.
Q: When the provider goes over the labs, but the labs are billed by a different department, can the provider still use the time they go over the labs?
A: Yes, they can bill the time reviewing the lab results.
Q: My question is for 2023 Inpatient billing based on MDM, under the data section: Which labs would we be able to give credit for? In outpatient we give credit for POC labs. Will that be the same for inpatient?
A: You can count any labs that are not billed by the provider. In an inpatient setting it is likely that most diagnostic procedures would be billed by the facility so you can count them.
Q: The guidelines for initial hospital care no longer indicate that the codes are to be used to report the first hospital inpatient encounter by the admitting physician. Does this mean consultants can choose to report an initial hospital inpatient encounter versus a consultation? Whichever is more advantageous?
A: The answer depends on the purpose for the consultation. If the purpose of the consultation is for the consulting provider to assume care, the service cannot be billed with a consultation code.
However, to use a consultation the following requirements must be met:
- The purpose of the consultation is to determine if it is appropriate to transfer care to the consulting provider; AND
- The consultation must be requested by an appropriate individual (insurer, social workers, attorney, etc.); AND
- A report for the requestor must be created.
Q: What would be an example of an acute, uncomplicated illness or injury requiring hospital or observation level of care? Concern: I think the AMA’s deletion of so called “confusing guidelines” when it comes to consultations is only going to cause more confusion. I fear the old debate of what was the intent of the requesting physician is going to reemerge due to the removal of the language of a type of service to determine whether to accept responsibility for ongoing management of the patient’s care or for the care of a specific problem. I also think the removal of the definition of transfer of care was a mistake. Sigh!
A: The answer depends on the purpose for the consultation. If the purpose of the consultation is for the consulting provider to assume care, the service cannot be billed with a consultation code.
However, to use a consultation the following requirements must be met:
- The purpose of the consultation is to determine if it is appropriate to transfer care to the consulting provider; AND
- The consultation must be requested by an appropriate individual (insurer, social workers, attorney, etc.); AND
- A report for the requestor must be created.
Q: Aug CPT Assistant article E/M Revisions 2023 states: “For 2023, code 99241 is deleted and codes 99242-99245 have been revised to describe a patient seen for the first consultation visit only. Prior to Jan 1, 2023, when a subsequent consultation for the same patient is provided, code 99241 may be reported again. Starting in 2023, when an office/outpatient follow-up or subsequent visit after a consultation is provided to the same patient, an established office or other outpatient visit code should be reported.” I understand follow-up visits initiated by the consultant/patient should be reported using established codes 99212-99215 but what if there is an additional request for consultation by a requesting physician for a different problem or even the same problem…are they saying once a consultation has been reported all future visits are reported as established 99212-99215?
A: Our interpretation of the guidelines is that if all three criteria, as described above are met, a second consultation visit could be billed. It seems logical that this situation may occur if a period of time has elapsed since the initial consultation OR if the patient’s condition changes significantly.
Q: 2023 E/M Code and Guideline Changes AMA (page 7 of 42) states: The risk of complications and/or morbidity or mortality of patient management. This includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). When the physician or other QHP is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report is not counted toward the MDM when selecting a level of E/M services. If we are reporting a separate CPT code for a cardiac stress test (professional interpretation) can we consider this towards the risk element of MDM?
A: No, if the service is being bill with a CPT by the provider, such as a cardiac stress test, it cannot be counted towards selection of level of service.
I understand we cannot count this towards the data element of MDM, but wondered if it could be considered for the risk element? The guidelines are confusing being that they say the risk includes decisions made associated with diagnostic procedures, but yet later they say not counted towards MDM if separate CPT code is reported. Yes, the information gained from the cardiac stress test would be considered in determining risk.
Download this blog as a PDF, click the button below.
Questions or Comments?