Article Detail - JE Part B

The following questions and answers (Q&As) are cumulative from the Part B Ask the Contractor Meeting (ACM). Some questions have been edited for clarity and answers may have been expanded to provide further details. Related questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed this directly with the provider. This session included pre-submitted questions and verbal questions posed during the event. Please note our disclaimer that these are accurate as of this publishing and may have future updates.

Updates and Reminders:

• For coding advice, seek external sources such as the AMA, AAPC or specialty societies
• Watch our Noridian website for CMS Telehealth updates after September 30, 2025

Written Pre-Q/A:

Q1. The CMS list does not include CPT 90480 (COVID vaccine administration). Is this an oversight or are we not allowed to bill G2211 when 90480 is performed at the same encounter as an Evaluation and Management (E/M) visit?
A1. Yes, this was an oversight. We had reached out to CMS and requested an update to the list of covered vaccine codes that would be allowed under Change Request (CR) 13705. It also includes influenza, pneumonia, and hepatitis B administrations (G0008, G0009 and G0010). This has been fixed and you may rebill or reopen the claims.

Q2. When a clinic RN or PharmD places a phone call with a patient, can we bill CPTs 98966-98968 (phone calls for assessment and management) that is incident-to a physician or advance practice physician (APP)? Can we append modifier 93 or could we bill CPT 99211 instead?
A2. CMS' position is that CPT codes 98966-98968 (telephone assessment and management services) may NOT be performed by nurses or Pharm D's incident to and subsequently billed by the non-physician qualified healthcare practitioner (QHP) or physician. These CPTs still fall under E/M and are intended where face-to-face encounter is not expected and require medical decision-making that must be personally performed by the physician or non-physician QHP during the encounter.

To bill CPT 99211 via telehealth, both medical necessity and incident-to rules must be met (i.e., established patient, nurse carrying out the provider's plan, direct supervision, etc.). A callback simply to provide test results from a previous visit, would be included in the previously billed visit and may not meet separate medical necessity. If audio only (with beneficiary permission), remember to bill POS 02 or 10 and append modifier 93. For more incident to information, please read the CMS Internet Only Manual (IOM) Publication 100-02, Chapter 15, Section 60 and for Telehealth CMS Medicare Learning Network (MLN) 901705 "Telehealth & Remote Patient Monitoring" Booklet.

Q3. If moderate medical decision-making is documented and the teaching physician does not see the patient, but their participation meets the supervision requirements; do we bill a level three (99203 or 99213) with GE modifier?
A3. Yes, but only under certain circumstances. Under the primary care exception, in certain teaching hospital primary care centers, teaching physicians can bill certain services that residents provide independently without teaching physicians present, but the teaching physicians must review the care. Lower and mid-level complexity E/M services may be billed with modifier GE (service performed by a resident without presence of teaching physician; under primary care exception). CMS MLN Guidelines for "Teaching Physicians, Interns & Residents."

Q4. Per Medicare guidelines, all participants of a shared visit should be identified "in the medical record". Is it sufficient if each provider in the same clinic documents and signs their own note, and states that they saw the patient with an MD and/or Advanced Practice Provider (APP), but does not specify them by name?
A4. Yes. Since there is not split/share in the office, and the patient sees the APP and then the physician, each provider would document the portion of the visit they performed and sign the medical record to have both the physician and practitioner identified. It would not be necessary to have each provider mention the other person by name. It could be billed under the physician, where both would perform and document their portions. Read more in the CMS Internet Only Manual (IOM), Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.18.E.

Q5. When an E/M leads to a decision for a minor procedure the same day, and allows more than the procedure, would it be appropriate to report just the E/M and no procedure code, if documentation does support both?
A5. No. Providers cannot report the related E/M service to replace the procedure code. Related E/Ms on the same date of service as the minor surgical procedure are included in the payment for the procedure and shall not be reported separately. Based on CMS National Correct Coding Initiative (NCCI) Policy Manual Chapter 1.

Q6a. When documentation indicates a scenario for treatment based on test results, such as "if the test is positive, then we will prescribe Augmentin," would this be considered documented evidence that a provider is considering prescription drug management for moderate risk?
A6a. Possibly. All elements of Medical Decision-Making (MDM), per the CPT E/M Guidelines, would have to be taken into consideration before assuming that prescription drug management is always going to be moderate. Two of the three elements for the level of MDM must be met or exceeded. Therefore, we cannot say that the prescription for Augmentin, based on test results, would be considered moderate risk.

Q6b. Per the note, "If the physical therapy does not help within 3 weeks, we will proceed to major surgery". At this encounter, would we consider just the risk of performing physical therapy, or would we consider this a decision for major surgery?
A6b. No. This is not considered a decision for major surgery if the patient has not decided at this encounter. If the outcome of physical therapy is unknown, then your practice can consider the risk of physical therapy.

Q7. For E/M level, chronic condition indicates "a problem with an expected duration of at least one year or until the death of the patient". However, NCD 270.1 A, indicates "chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence". For this purpose, would a diabetic foot ulcer longer than 30 days be considered chronic rather than acute condition?
A7. Yes. For E/M purposes, the American Medical Association (AMA) CPT definitions would be followed to determine a chronic condition. CMS develops the National Coverage Determination (NCD) policies for certain procedures that are separate from CPT and two separate guidelines. For E/M, follow the CPT definitions.

Q8. For the Medicare AWV, the provider documents "Awake, Alert, and oriented x 3", as this definition would indicate there are no cognitive impairments. Does this meet requirement #5: "Detect any cognitive impairments patients may have", and if not, what additional information would be needed?
A8. No, that would not be an appropriate cognitive assessment. There are screening tools that are appropriate to determine cognitive fitness to use during the Initial Preventive Physical Exam (IPPE) or Annual Wellness Visit (AWV).

Q9. For a data analyzed E/M element, a handheld doppler ultrasound for fetal heart tones would not be billed separately with CPT 76815 (ultrasound; pelvis) when imaging is not saved. Would the analysis of the imaging by the provider be considered an independent interpretation of a test not separately reported, or review of one unique test?
A9. Possibly. Tests not separately reported and performed by another provider may meet independent interpretation. When the same provider performing the E/M service uses the handheld doppler for the ultrasound, that would be reviewing results under Category 1. Documentation of ultrasound findings would need to be indicated in the medical record to support the provider's review.

Q10. Can a Licensed Clinical Social Worker (LCSW) bill directly or incident to for CPT 96127 (Brief screening for emotional/behavioral assessment; e.g., depression, anxiety, attention-deficit, or hyperactivity disorder [ADHD], eating disorders, etc.), with scoring and documentation, per a standardized instrument?
A10. Yes for either. CPT 96127 can utilize the Patient Health Questionnaire (PHQ-9), General Anxiety Disorder scale (GAD-7) and/or Depression Anxiety Stress Scales (with 4-point Likert-type scale; DASS-21). The assessment must be provided and scored by trained administrative staff. The LCSW could bill directly if enrolled in Medicare and working within their State guidelines and Scope of Work. Otherwise, this service would have to be performed incident to and billed by the supervising physician or other qualified health practitioner (QHP).

Q11. Sometimes, when we call the Provider Contact Center, they are closed. Is there an alternate line that can be used?
A11. No. Medicare Administrative Contractors (MACs) are unable to provide a voicemail to callers who attempt to reach Noridian outside of regular business hours. In accordance with CMS Internet Only Manual, Publication 100-09, Chapter 6, Section 30.4.6, MACs will be available 8:00 a.m. through 4:00 p.m. for all time zones of the geographical area serviced, Monday through Friday. Noridian's hours of operation are 8-5 Pacific time for JE providers and 8-6 Central time for JF providers.

CMS grants MACs 8 hours of training time per month that the contact center staff are unavailable on Fridays. Noridian has both training and holiday closures published on each of our jurisdiction pages.

Noridian receives approximately 5,000 phone calls a day. All calls are answered in order of receipt with an average wait time of 60 seconds (time may vary depending on time of day).

Q12. What needs to be documented to give credit for high toxicity? For example, provider documents vancomycin and labs are brought into the note, but doesn't document to monitor. Does this support the monitoring of high toxicity?
A12. Possibly. The purpose for ordering the lab should be documented in the medical record and would support the monitoring requirement. If the lab order does not indicate the (drug name) monitoring, this may not be considered for the E/M risk element.

Q13. Is a modifier 25 needed with an E/M when billing with CPT 95251 (Continuous Glucose Monitoring; analysis, interpretation, and report) on the same day?
A13. No. Since the NCCI does not show any coding combinations, there should be no reason to append modifier 25 on the E/M. Always check the NCCI website first before billing. A reminder that CPT 95251 services (e.g., interpretation and report of the data analysis) cannot overlap with the separate E/M visits.

Q14. Please clarify if a neurological psychologist (PhD) can bill evaluation and management (E/M) services (99202-99215)?
A14. No. Medicare only allows E/M services for specific physicians and non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA) and certified nurse midwife (CNM)), whose Medicare benefit permits them to bill these services. Per CMS IOM, Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.4.

Q15. Can procedure CPTs 51550-51595 be used for laparoscopic cystectomy "open" procedures?
A15. Yes, the default is "open" for all of these CPT codes. If a practice wants to perform the procedure laparoscopically or with robotics, it is still the same procedure. When CPT designates the same code for a laparoscopic and open procedure, they are designating the values for the code (work, practice expense and liability) are assigned as identical. Per the NCCI Policy Manual, Chapter 1, E/M services performed, on the same date of service, as a minor surgical procedure are included in the payment for the procedure and are not reimbursed separately.

Q16. What CPT or HCPCS code should a facility report for a patient receiving dental services (under general anesthesia) in the outpatient hospital setting?
A16. HCPCS G0330 (facility services for dental rehabilitation procedure(s). This is only billing education and does not guarantee payment. CMS coverage for dental services can only be paid when medical services are inextricably linked to the clinical success of other Medicare-covered procedures CMS Medicare Dental Coverage. "In general, ancillary services and supplies furnished incident to dental services can only be paid, if the dental services being performed during the dental rehabilitation, are considered inextricably linked. If they are not considered inextricably linked, they are not covered by Medicare under the SSA1862(a)(12). Consequently, the facility fee associated with the dental rehabilitation would then also, not be covered by Medicare." CMS IOM, Medicare Benefit Policy Manual, Publication 100-02, Chapter 15.

Q17. Is HCPCS G2211 (E/M visit complexity add-on ) ever payable for place of service Patient's Home (12) and home-based E/M visits (99348-99350)?
A17. No. CPT G2211 is only accepted with primary E/M codes (99202 - 99215). With only those new and established E/M codes, it may be added as telehealth in the patient's home. G2211 would not be allowed with home visit codes.

Q18a. How do I submit documentation that goes with an appeal, claim and or reopening?
A18a. Claims instructions are found on the Noridian Website. Sign up for the Noridian Medicare Portal (NMP) that provides a way to Reopen claims, upload appeals documentation, etc.

Q18b. How to bill for pain pump medication?
A18b. Follow the Noridian Billing and Coding Article-Implantable Infusion Pumps for Chronic Pain.

Q18c. What can be done if payment for pain pump medications do not cover cost? Can we send a copy of the invoice in appeal?
A18c. Yes, an invoice could be attached with an appeal; however, will not guarantee additional payment. Always check the Average Sales Price (ASP) quarterly drug pricing as a couple drugs were just increased in 2025.

Q19. What code is correct to use when Cryoneurolysis is treated with the Iovera system for the knee?
A19. Per the CMS Billing and Coding Article, Cryoneurolysis Instructions, bill with 0441T (ablations, percutaneous, cryoablation, including image guidance; lower extremity, distal and/or peripheral nerve), for the Iovera system for use in the knee.

Note: Both CPTs 64640 (destruction by neurolytic agent; other peripheral nerve or branch) and 64624 (destruction by neurolytic agent, genicular nerve branches including imaging guidance) are not appropriate for Medicare billing, because they require destruction of the targeted nerve(s). The Iovera system is temporary and not destructive. Therefore, these two CPTs are not appropriate for Medicare billing.

Q20. When an APP or non-physician practitioner (NPP) provides a service that meets all the incident-to requirements, does both the APP and supervising provider, or either one, need to sign or and date?
A20. The provider performing the visit and authoring the documentation should sign and date the medical record. CMS IOM, Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 60 states there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment, of which the service being performed by an APP is an incidental part.

Q21. What specifically needs to be documented when a patient is on high toxicity medication? Would "monitor for high toxicity" qualify for E/M credit?
A21. No. Per the AMA E/M guidelines, the monitoring may be performed by lab test, physiologic test, or imaging. The reason for ordering these tests would be supported by the need to monitor the high toxicity medication. Documenting in history and the exam does not qualify as monitoring. Noridian will not provide specific language a provider needs to document. The provider is responsible to assessing the level of risk management based on the patient's specific risk factors. Also, see QA#12 as similar.

Q22. When a consultation order is in place, can an interprofessional consultation (CPT 99451) be billed when a resident sees the patient and the teaching physician does not see the patient; but the physician reviews the record and provides recommendations to the referring provider?
A22. 99451 is considered provider-to-provider and must have the patient's consent to approve out-of-pocket coinsurance and unmet deductible expenses.

The interprofessional consultations state the consultant does not have a face-to-face visit with the patient. The resident under the teaching physician saw the patient. The interprofessional consult is reviewing medical records from the treating provider (the one requesting the consult and not the resident) and providing a written report back to the treating/requesting provider.

If the teaching physician only reviewed the referring provider's records and provided a written report, that would qualify as interprofessional consult. The resident's medical records would not be part of the consultation. Read more CMS MLN006347 "Guidelines for Teaching Physicians, Interns & Residents".

Q23. According to the CMS E/M Guide (MLN 006764), members of the care team may collect information under the History and Examination section. Can you define care team in this context? If the patient is seen by a non-physician practitioner initially performs the history and exam, and a physician subsequently assumes care, would the physician need to review and agree with all the documentation?
A23. For the context of the "care team" in MLN 006764, we will check with CMS. In 2018, CMS published an FAQ regarding parts of the history can be documented by ancillary staff CMS E/M Visit FAQs Under Medicare Physician Fee Schedule (MPFS). Documentation needs to be reviewed by the billing physician. Additionally, any information documented by others needs to be reviewed and verified to ensure accuracy and compliance with any E/M code submitted for reimbursement.

Q24. Can an APP or NPP report modifier 57 (initial decision to perform major surgery; day before or day of) if they see the patient the night before and the surgeon sees the patient the next day? Who bills the E/M with modifier 57?
A24. No. It has to come from the surgeon. CMS IOM, Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.1.B states the initial consultation or evaluation of the problem is by the surgeon to determine the need for surgery. Modifier 57 would be appended to the E/M visit when it is the day of, or day before a major surgical procedure.

Verbal Q/A:

Q25. For the 2025 chimeric antigen receptor (CAR) T-cell therapy policy billing, we replaced the Category III code 0540T with CPT 38228 (administration, autologous). We previously billed with the 0540T and received payment. We are enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS) program and append the KX modifier to acknowledge. Why are we receiving denials?
A25. Noridian is aware of claims processing issues related to the new CPT code 38228 (which became effective 1/1/25) and are seeking further information from CMS. We will follow up once more information can be gathered. Please reach out to your jurisdiction customer service line for specific denied claims.

Q26. Is a new patient E/M bundled or allowed with modifier 25, when minor procedures and injection performed during the 10-day global period?
A26. In general, related E/Ms (new or established patients) on the same date of service as the minor surgical procedure are included in the payment for the procedure and shall not be reported separately. Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E/M service for this work.

Medicare Global Surgery Rules prevent the reporting of a separate E/M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient. Based on CMS National Correct Coding Initiative (NCCI) Policy Manual Chapter 1. Just because the patient is new does not mean the E/M can be unbundled.

Q27. Under the supervision and incident to rule for Registered Nurses (RNs), would they be covered for a surgical procedure for Vagus Nerve Stimulation (VNS) needle placement?
A27. No. Surgical procedures are not performed incident to, even in the office, and require personal supervision (i.e., performed by a qualified provider), specifically one who can demonstrate training and experience in all stages of management. An RN would not be included for the independent practice of the procedure CPT 64568 (incision for implantation of cranial nerve [e.g., vagus nerve] neurostimulator electrode array and pulse generator).

In this case, the issue may be an "insertion of a needle" and may be confused with an injection, which is included in the nursing scope of practice. It may be possible, once the device is in place, to allow an office nurse or clinician to regulate or test incident to the supervising qualified provider. However, it would be part of the E/M (unless it was at the initial install), which is part of the 64568 procedure. If it was queried or managed at a later date, it is part of that E/M.