Article Detail - JE Part B

Written Pre-Q/A:

Q1. If a patient has Medicare as a secondary insurance, should we follow the billing rules as set forth by Medicare, or by the primary insurance? Similarly, if a patient has a Medicare Advantage Plan, should we follow Medicare billing rules or are the rules set by the administrator of the Advantage Plan?
A1. When Medicare is primary, follows Medicare rules and when Medicare is secondary, follow primary insurer rules first and then Medicare. Medicare Advantage plans comply with both Medicare and their own rules; however, must follow CMS National Coverage Determinations (NCDs) and their Medicare Administrative Contractor (MAC) jurisdiction Local Coverage Determination (LCD) policies.

Q2. When a patient has sleep apnea well controlled on a Continuous Positive Airway Pressure (CPAP) machine, and the provider recommends continuing with CPAP therapy, would this be 'low' risk or "moderate" on the medical decision-making (MDM) table 3rd column? What if a change was made to the settings during the visit and how about an initial prescription?
A2. This looks low risk without any other changes besides reviewing the data card. However, risk for MDM will depend on many factors, so there's no one answer. "Prescribing" is only one component of the MDM. Does the patient have other diagnoses, amount, and/or complexity of the visit? It's up to the physician's office. Make sure that the patient's condition, treatment plan, any orders, etc., are well documented.

Q3. Per Medicare's Claims Processing Manual, Publication 100-04, Chapter 8, Section 150; physicians are paid a flat fee of $500 to train patients for home dialysis. The facility is billing CPT 90989 or 90993 for home dialysis training and is reimbursed under the End Stage Renal Disease (ESRD) Prospective Payment System (PPS). How is this billed by the physician?
A3. CPT codes 90989 or 90993 are billed for the physician providing the training. When the physician is enrolled under the facility, the training is billed to Part A. If the physician is billing under a clinic, bill to Part B.

Q4. Is CPT 99459 (add on pelvic exam with E/Ms) billable with G0101 (cervical or vaginal cancer screening; pelvic and clinical breast exam) and Q0091 (pap smear)?
A4. No. 99459 would not be allowed separately for a pap and/or pelvic exams (Q0091 or G0101) as those services are bundled. Since this add-on code is a practice expense, covers speculum costs and staff time minutes (e.g., chaperone and room setup time), it should be only billed with E/M office visits. Check out the Add-on Code NCCI links on the CMS website.

Q5. Can the Continuous Glucose Monitor (CGM) CPT 95251 be completed "incident to" or can only a MD, DO, NP or PA bill this code?
A5. Yes. CPT 95251 (Ambulatory CGM of interstitial tissue fluid via a personal wear subcutaneous sensor for a minimum of 72 hours; analysis, interpretation, and report) is only to be billed by an MD, DO, NP or PA. However, under "incident to", a medical assistant, nurse (both registered and licensed professional), or a Certified Diabetes Care and Education Specialist (CDCES) may only perform certain elements as they cannot bill Medicare.

Q6. What can our solo private practice for psychiatry learn to avoid future Medicare audits for CPT 90833 (psychotherapy)?
A6. For psychotherapy add on CPT 90833, the psychotherapy and medical components of the notes must be significant and separately identifiable. Make sure each requirement can be identified to determine if they are met. The E/M key components and total time must be reflected in the medical record. To assist with passing the audits, read the Mental Health pages on both Noridian and CMS; plus attend Noridian's two-part mental health annual webinars and save the PDFs for references.

The rules used for audits depend on several factors including changes in billing patterns, unusual billings on regular reviews and other items. Pre or post-pay reviews have different requirements. Some will look at the top 15 percent comparison with peers, while other reviews follow other indications. Documentation is the key to support services billed.

Q7. Would the E/M discussion of "management component" with non-health care professionals, include inpatient discussions between a physician and nurse at the patient's bedside?
A7. No. Per the American Medical Association (AMA) E/M guidelines, this discussion would include professionals who are not health care professionals. Examples include an attorney, case manager, teacher, or parole officer.

Q8. Can CMS provide the supporting documentation on this policy around Medicare Secondary Payer (MSP) with Employer Group Health Plan (EGHP) primary discharge for dialysis clinics and Part B beneficiaries?
A8. Medicare is only secondary to an EGHP for 30 months. We are not aware of any policy of CMS restricting patient discharges from out-of-network providers to an in-network provider for the beneficiary.

Q9. Does "incident to billing" apply to both PAs and NPs in an Urgent Care setting when the Urgent Care is owned by the same provider group?
A9. Yes it could. Incident to rules apply in all appropriate allowable settings and that includes the Urgent Care setting in place of service (POS) 20 with non-facility pricing. Reminder that incident to is not allowed in a facility setting.

Q10. What is included in the global package if weight loss surgery is decided in July and not scheduled until December?
A10. If the procedure has a 90-day global, the day before is counted in the global package. A prolonged period should be billed as an E/M. The lesser 10-day global procedures only include the day of surgery.

The days included in the global package are determined based on a minor (0-10 days) or major (90 days) surgery. To reiterate, major surgeries include the day before the procedure, day of, and 90 days after.

The MLN booklet titled Global Surgery and the CMS Internet Only Manual (IOM), Claims Processing Manual, Publication 100-04, Chapter 12, Section 40 clarifies.

Q11. What is the requirement to support billing with modifier -80 for a physician (MD or DO) assistant-at-surgery?
A11. The operative note should clearly document the assistant surgeon's role during the operative session. It should include their name, credentials, and specific activities they performed.

Check Noridian's Medicare Physician Fee Schedule (MPFS) Fees and Indicators listing and descriptors for codes. For example: CPT 45385 has "Assistant Surgeon" indicator of "1", meaning "Statutory payment restriction for assistants at surgery applies to this procedure. Assistant surgeon may not be paid." CPT 27447 has indicator "2", meaning "Payment restriction for assistants at surgery does not apply to this procedure". Assistant surgeon may be paid "Payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid".

Q12. When a Medical Oncologist evaluates the patient, reviews labs, and orders imaging (i.e., PET scan) for re-staging the cancer disease, would a separately identifiable E/M with modifier 25 on the same day be allowed with the scheduled chemotherapy infusion?
A12. Yes, the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.5, states to bill an E/M visit with a 25 modifier, it must be a significant, separately identifiable E/M service.

Q13. Why does Noridian bundle radiation treatment services (77427-77435), although these codes have an indicator of "no global days"?
A13. Global days are not the only bundling edits. Please check the National Correct Coding Initiative (NCCI) page on the CMS website for code pair edits. Some bundled service codes cannot be unbundled.

Q14. If our mobile unit goes to a location not owned by our facility, what name and address should we have in Item 32? If the mobile unit goes to a location owned by our facility, which address should be in Item 32?
A14. When using mobile unit POS (15), a different place of service is expected to be indicated in Item 32. Indicate the address where the service was performed.

Q15. Can G2211 (complexity add-on) be billed with yearly follow-up visits for a patient in remission from cancer?
A15. Yes. G2211 may only be reported as an add-on code to E/M office or outpatient visits 99202-99205 or 99211-99215. The provider has ongoing medical care for the patient with consistency and continuity over time. Documentation would include continuous and active collaborative plan of care between the provider and the patient. If the documentation for the annual visit meets these requirements, it may be possible to use add-on code G2211.

Q16. Can a physician bill critical care services and a discharge service on the same day if the patient is transferred to another facility or expires?
A16. Depends. In situations when a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation), as long as the medical record documentation notes that: 1) the other E/M visit was provided before the critical care, and at a time when the patient did not require critical care; and 2) the services were medically necessary; and 3) the services were separate and distinct with no duplicative elements from the critical care services occurring later in the day. If so, modifier -25 should be appended to the critical care E/M on the claim for this day.

Follow-up Q16. When one provider works the day shift and another the evening shift, is critical care split and shared billing appropriate, when a physician and advanced practice provider (APP) do not work collaboratively on patient management?
Follow-up A16. CMS pays the practitioner who performs the substantive portion of the visit, if they are part of the same group. Read more at 2024 "Updates for Split or Shared E/M Visits".

Q17. When a patient is transferred to another physician for post-operative care, how do we report the surgical CPT with modifier 55 and what about an office visit?
A17. Physicians utilize the same global surgery CPT code and bill with modifiers -54 and/or -55. Report the same date of service the surgery was performed. In the CMS-1500 narrative field (Item 19), include the date span responsible for post-op care. Both the surgeon and postop care provider must keep a copy of the written transfer agreement in the beneficiary's medical record and add up to the 90-day global. Read more under the MLN booklet titled Global Surgery.

Follow-up Q17. If the surgeon performed one post op visit and the remaining post-operative care was managed by another physician, does the second physician report the CPT with modifier 55?
Follow-up A17. Yes, if separate medical practices. When different physicians in a group practice participate, the group bills the entire global package. The surgeon bills the surgical CPT with modifier 54 for the surgery component. On the next line, bill the same code with modifier 55, indicating one day of postop care.

The physician performing the remaining postop days bills separately with modifier 55 and dates responsible for postop care. Postop care modifier 55 is only applicable with the surgery code. Read more at Medicare Learning Network (MLN) Global Surgery Booklet.pdf.

Q18. When a medically necessary eye exam is reported as an E/M CPT, would the visual acuity testing (CPT 99173) be considered an analyzed test?
A18. No. Per the AMA, the ordering and actual performance and/or interpretation of diagnostic tests and studies during a patient encounter, are not included in determining the levels of E/M services, when the professional interpretation of those tests or studies is reported separately by the physician or other qualified health care professional reporting the E/M service.

Tests that do not require separate interpretation (e.g., results only) and are analyzed as part of the medical decision-making (MDM), do not count as an independent interpretation.

However, it may be counted as ordered or reviewed for selecting an MDM level. If a test or study is independently interpreted to manage the patient as part of the E/M service, but is not separately reported, it is part of MDM. CPT 99173 is not separately payable.

Q19. When a patient is in a current Skilled Nursing Facility (SNF) stay and is brought to a physician clinic for an E/M visit, can the visit be reimbursed?
A19. Yes, when the patient is in a covered SNF stay and brought to physician clinic, submit the correct level of E/M visit with the place of service 31 for the Part A covered SNF stay. If not covered under Part A, use place of service 32. Read more in the SNF Billing Reference on the CMS website.

Q20. How can we avoid our claims denying and appealing when the patient's visit diagnosis has nothing to do with their open Medicare Secondary Payer (MSP) case?
A20. Unfortunately, there may be no way around the appeal. Our systems currently reject any codes that are an exact match and/or may be related to the diagnosis code(s). Providers need to submit a completed "MSP B Correspondence" form for each claim, indicating "not related to the open file". Check that the submitted diagnosis code(s) are not related to the Non-Group Health Plan (NGHP) file, etc.

Q21. Can our mid-level providers that assist with surgery document and sign their name to the physician documentation and receive credit to bill?
A21. It depends on the surgical CPT and if Medicare allows to have an assistant surgeon bill or billed separately under the surgeon. Billers and practitioners can find all allowed codes under the Fee Schedule pages. From our Fee Schedule pages, refer to Answer 11 and consider an addendum to the medical record to include the work from the NPP.

Q22. Since the current CMS data is from 2022, what is the process to submit a request for current physician comparison data by CPT code and specialty?
A22. Check the CMS Provider Data Catalog; last modified October 11, 2024, that includes the National Downloadable File, Clinician Public Reporting, Utilization Data, etc.

Q23. If a hospital owns a clinic, but not billed as hospital-based (1206G primary care clinic), can you bill "incident to", since the expenses are not reported on the cost report for this type of clinic? Does it still apply if there's no direct expense by the physician?
A23. No. Incident to would not apply if billing on a UB04 with POS 19 or 22. If billing CMS-1500 with POS 11, then incident to may be performed. They could perform split shared services in this scenario if the criteria is met. Note: 1206G appears to be CA designation and not Medicare.

Verbal Q/A:

Q24. Providers are ordering bilateral facet injections, but our radiologists are only able to do one side per day and we are receiving claim denials. What type of care plan needs to be included and what we are potentially missing?
A24. Bilateral services must be performed on the same day. The policy allows a maximum of two unilateral or four bilateral per session. One spinal region is allowed per session with one or two levels unilateral or bilateral per session. When determining a level, count the number of facet joints injected, not the number of nerves injected. Therefore, if multiple nerves of the same facet joint are injected, it would be considered a single level.

If providers are performing a bilateral, it's considered one for both sides.

Q25. My understanding is that for minor procedures there is an inherent E/M in each procedure. Our doctor is stating that when a patient comes in for a new problem; such as right shoulder pain, and he diagnosed right shoulder osteoarthritis, then decides to perform a joint injection, we can bill an E/M service separately. Can you clarify how this would be billed for new patients?
A25. Providers would have to meet the separate E/M requirements. There is specific language in the National Correct Coding Initiative (NCCI) Manual that states just because they are a new patient, does not mean that an E/M is medically necessary on the same day as a procedure. Look at documentation to see if anything is separately identifiable from the joint injection in order to bill the E/M.

Q26. In the stereotactic radiosurgery (SRS) CPT 61796-61798 description, it mentions physician presence as a requirement for the neurosurgeon, but the type of service we provide does not require the frame placement or use that machinery. We are trying to determine whether the physician needs to be present for the treatment session in order to bill?
A26. Yes. For SRS, no one physician may bill both the neurosurgical codes and the radiation oncology 77xxx codes. Radiation oncologists and neurosurgeons have separate CPT billing codes for SRS. The comprehensive CPTs that use SRS with either particle beam, gamma ray, or linear accelerator for cranial lesions (61796, 61797, 61798, etc.), may be billed by the neurosurgeon, as one member of the team. This happens, when and only when; this "physician" is (a) present, (b) obviously the procedure is medically necessary and (c) s/he is fully participating, in the coded course.

If either the radiation oncologist or the neurosurgeon does not fully participate in the patient's care, that physician must code by appending the appropriate modifier 54 and then the other physician bills with appended modifier 55 to split the global procedure(s). Make sure that the date span in Box 19 narrative is reflected.

The medical record must clearly indicate the critical nature of the anatomy or other circumstances necessitating the services encompassed by this code. They must be physically present during the entire process of defining the target volume and structures at risk.

Q27. We have an urgent care with a number of providers with different specialties. What is your guidance with the new versus established patient rule? If we have a patient that sees an internal medicine provider, then three months later they see a hospitalist, could that be billed as a new patient visit as well?
A27. Depends. If the providers are completely different specialties, new patient visits could be billed for both visits. If they are the same specialty, only the first visit will be new patient. If the doctor is covering for the doctor who saw the patient the first visit, then the second visit would be an established patient visit.

Q28. We recently opened a mobile clinic and we were billing with a 99386 (initial comprehensive preventive medicine E/M service for new patients between the ages of 40 and 64) but they are being denied as noncovered charges. Are we supposed to be using a G-code?
A28. Yes. Medicare has different codes for annual wellness visits, G0438 (initial annual wellness visit) and G0439 (subsequent annual wellness visit). We suggest checking the patient's eligibility because another provider could have previously billed.

Q29. If the provider assesses the patient's injury and determines there's a fracture, is an E/M with modifier 57 appropriate with fracture care the same day?
A29. Yes. If the procedure has a 90-day global period, the decision to determine the fracture care would be able to be billed with modifier 57.

Q30. We perform a septoplasty, CPT 30520, with additional services. The septoplasty has to be pre-authorized for Part A and our claim for additional services under Part B pays. However, it may be recouped because the hospital did not obtain this authorization. How do we get the codes that don't require authorization paid?
A30. Because all related codes to the code that requires prior authorization will be performed, if the code that requires the authorization is not approved, then all related services will be denied. Here's the current list of services:

• blepharoplasty
• botulinum toxin injections
• panniculectomy
• rhinoplasty
• vein ablation
• spinal cord neurostimulator
• cervical fusion
• facet joint intervention for pain management

Septoplasty is not listed at this time. Check our Noridian Part A website, under Medical Review, Prior Authorization

• JE A Medical Review-Prior Authorization
• JF A Medical Review-Prior Authorization

Q31. We are a retail pharmacy and billing for oral oncology medications. Where are the requirements for patient signatures if we ship the medication to the patient?
A31. When the method of delivery is shipping (also known as Method 2), Method 2 does not require a signature. Here are the proof of delivery requirements:

• Beneficiary's name
• Delivery address
• Delivery service's package identification number, supplier invoice number, or alternative method that links the supplier's delivery documents with the delivery service's records
• Description of the item(s) being delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, long description of a HCPCS code, or a brand name and/or model number
• Quantity delivered
• Date delivered
• Evidence of delivery