Evaluation and Management Questions and Answers
The following questions and answers (Q&A) are cumulative from web-based training conducted. Similar questions were combined to eliminate redundancies.
- Care Plan Oversight (CPO)
- Critical Care Billing and Coding
- Evaluation and Management (E/M)
- New Patient vs. Established Patient Visit
- Transitional Care Management
Care Plan Oversight (CPO)
Last Updated April 2017.
Q1. Is it appropriate for a provider to bill for HCPCS G0179 and HCPCS G0180 without performing HCPCS G0181?
A1. Yes. CMS wants to provide an additional way for practices to receive credit for services provided but there are no requirements for providers to bill HCPCS G0181 or HCPCS G0182. The physician who bills the monthly CPO must be the same physician who signed the home health or hospice plan of care. Once home health care coverage ends, CPO is no longer covered.
Q2. Does Hospice have to be a terminal illness diagnosis? Does Home Health?
A2. Yes. Hospice coverage starts when a patient has been determined to have six months or less to live due to their illness. For home health coverage, there are special requirements for the patient to be eligible. View more home health requirements information at CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 20 .
Q3. Is it appropriate for a provider to bill CPO for a patient in assisted living?
A3. Yes. Only if the patient is under the Home Health or Hospice program. If it is determined that the assisted living facility (also called personal care home, group home, etc.) does not primarily provide the services below, Medicare will cover reasonable and necessary home health care.
- Diagnostic and therapeutic services for medical diagnosis;
- Care of injured, disabled or sick persons;
- Rehabilitation services or other skilled services needed to maintain a patient's current condition or to prevent or slow further deterioration; or
- Skilled nursing care or related services for patients who require medical or nursing care.
Q4. Can a specialist (e.g. orthopedic surgeon) bill HCPCS G0180 or HCPCS G0181 during the post op visit after hip surgery?
A4. Yes. If the services are unrelated to the surgery, the surgeon may bill the HCPCS G0181, by appending modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period). Be sure the documentation supports the service. Enter the date, procedure code and ICD-10 diagnosis of the original procedure/surgery in item 19 of the CMS-1500 claim form. Unless the surgeon is the physician certifying the patient for Home Health and billing for that service, HCPCS G0180 is not appropriate.
Q5. Is a Family Nurse Practitioner (FNP), without a supervising physician, eligible for CPO?
A5. Under provisions of the Balanced Budget Act of 1997, Nurse Practitioners (NPs), Physician Assistants (PAs) and Clinical Nurse Specialists (CNSs), practicing within the scope of State law, may also bill for care plan oversight.
These non-physician practitioners (NPPs) must provide ongoing care for the beneficiary through evaluation and management (E/M). They are not covered for CPO if they are contracted or employed by the home health or hospice service. The expectation for NPPs is that the patient's care must be a coordinated aspect with the home health agency or hospice during the month which CPO services were billed.
NPPs may bill when the following are met:
- Not a consultant whose participation is limited to a single medical condition, rather than multi-disciplinary coordination of care
- Combines his or her care with physician who signed plan of care (POC)
- Has examined patient
NPPs may not certify the beneficiary for home health care.
Q6. What are the five (5) eligibility criteria?
A6. Here are the five criteria.
- All documentation regarding initial eligibility criteria
- Date of face-to-face (F2F) encounter at time of initial certification
- Statement from community physician that is overseeing home health agency (HHA) services acknowledging that all 5 eligibility criteria met
- Dated signature below statement from a Medicare enrolled physician
- Must be at least a 60-day episode
Q7. How are providers able to validate their status as home health or hospice patient? Is there a way to do this online?
A7. Noridian Medicare Portal (NMP) users may access the date of home health or hospice via the NMP.
Q8. When services are provided by an MD and nurse practitioner (NP) or physician assistant (PA) within the same month (same practice), is it appropriate for providers to bill CPO?
A8. If the eligibility and criteria are all met, the NP/PA services can be added as "incident to" the physician's service and billed on one claim under the physician's name. Only one provider can bill. If two physicians bill, the second claim will deny as duplicate.
Q9. Please clarify the non-countable services such as discussions with a provider's nurse in the office, an HHA or hospice.
A9. Physician's time spent discussing with his/her nurse or the HHA/hospice nurse does not count toward the 30-minute requirement; however, physician's time spent working on a care plan after receiving the pertinent information from the nurse does count toward the 30 minutes.
Last Updated April 2015.
Q1. If one physician bills for an inpatient Evaluation and Management (E/M) visit with an AI modifier, then performs critical care later the same day, can both services
be billed on the same day?
A1. Other E/M services performed by the same provider earlier on the same day as critical care, may be billed appending the 25 modifier with careful documentation of the circumstances in the clinical record.
Q2. If two physicians, same specialty from the same group, provide critical care on the same day, should the time be combined or can they both bill?
A2. The time must be combined. The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. The first physician seeing the patient must have met criteria for CPT 99291. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician. Medicare considers physicians of the same specialty from the same group as a single billing entity. This is also true for cross-covering physicians from the same group even if their Medicare "specialty" may be different. Each provider of care should document his/her time spent providing necessary patient services.
Q3. Who should bill CPT 9929; the physician who sees the patient first or the physician with the most patient time?
A3. The initial physician seeing the patient must have met criteria for CPT 99291 for the time to be considered critical care. Total critical care time may be aggregated for all physicians seeing the patient on that day, billing under a single group entity that are providing critical care services for the same specialty and then billed under any one of the performing physician's National Provider Identifiers (NPIs).
Q4. If a physician performs 80 minutes of critical care, can we bill CPT 99292?
A4. Yes, if the documentation reflects necessary services meeting critical care criteria. The CPT manual, under the "Critical Care Services" section, includes a chart outlining time criteria for billing the critical care codes.
Q5. If the emergency department (ED) physician provides 70 minutes of critical care and the attending subsequently provides 60 minutes of critical care, how should we code for each of the physicians?
A5. When a patient requires critical care services upon presentation to a hospital ED, the ED physician reports either the critical care codes 99291 – 99292 or the ED outpatient codes but not both. The second physician, depending on the specialty, and whether from a separate billing entity, would bill either an initial or subsequent critical care codes.
Q6. If a patient receives critical care in the ED and is then admitted by and receives critical care from a different physician group, is it appropriate to append the 25 modifier to the ED physician code?
A6. No. The ED physician should bill for his/her critical care service (no modifier). When the same provider performs an E/M code along with critical care, then the use of modifier 25 would be necessary (on the regular E/M code). In the ED, the ED physician may not bill another E/M code if billing for critical care so the 25 modifier is not needed.
Q7.In what scenario should the ED physician be billing the critical care codes vs the highest level of the Emergency Room visit codes?
A7. The fifth level Emergency Room visit CPT code, 99285, reads: "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function."
This last requirement is similar to a requirement for Critical Care Services: "A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. "Both codes therefore apply to similar patient circumstances and both require "high complexity decision making", so the question will occasionally arise of when one code should be used instead of the other. The distinction is in the documentation of the duration, nature and necessity of the time spent personally providing one-on-one critical care services to that critically ill patient. Specifically, in contrast to the typical team approach to a variety of patients in an Emergency Room setting: "For any given period of time spent providing critical care services, the individual must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time." The record must make it clear that, for this critically ill patient, this full-time focus on the individual patient was necessary for, and was provided for, the full documented cumulative period of time, personally providing necessary critical care services. If the documentation does not convincingly establish that, these criteria were met and for a duration clearly qualifying as critical care time, it is not appropriate to claim as critical care. However, it may remain quite appropriate to bill a claim as 99285 if the criteria are met.
Note: Simple comments such as "45 minutes were spent providing critical care services" may be much less credible than descriptive explanations such as "due to marked liability of the patient's pressure, rate and rhythm and the repeated need to assess and adjust medications, I was required in constant one-on-one attendance with this critically ill patient for a total duration of 45 minutes, separate from any procedures."
Q8. After our cardiologist performed a pacemaker placement, critical care was then needed; however, the E/M was denied. Is the 25 modifier needed on the CPT 99291?
A8. In this scenario, the modifier 25 would be necessary on the CPT 99291. The records must clearly document why these services were medically necessary over and above those that are included in pacemaker placement.
Q9. If a person is in a coma, is the care provided considered critical care?
A9. No, not based on this alone and not based on patient condition alone. Critical care is provided for a "critical illness or injury (which) acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition." See the discussion that includes this quotation in CPT under "Critical Care Services." Both the patient's condition and the services being provided must meet critical care criteria.
Q10. Is it necessary to document start and stop times or just the overall amount of time spent providing critical care?
A10. Documentation of the overall time the physician(s) has spent providing critical care with the patient is acceptable, if the record is sufficient to support both that criteria for critical care are met and the indicated times are credible. See answer 7 Note: section for documentation example.
Q11. Is it correct that any critical care time a non-physician practitioner (NPP) performs has to be billed by the NPP?
A11. Physicians and NPPs critical care time cannot be aggregated. Each provider type must bill and document separately the time spent performing critical care. NPPs from the same group, providing services of a single specialty may aggregate their critical care time for a day and bill under one of the NPP's NPI.
Q12. If the medical doctor (MD) spends 77 minutes providing critical care and the NPP, in the same group, spends 15 minutes; can both 99291 and 99292 be billed?
A12. In this case, the criteria for a 99291x1 and 99292x1 have been met by the MD as the time he has reported is above 74 minutes but less than 105. The NPP has not met the minimum time for the initial critical care. The NPP's time may be billed with a non-critical care E&M (for example 99231) when the care is medically necessary above and beyond what the MD is providing.
Q13. Can you explain split/share E/M billing?
A13. When a hospital E/M (inpatient/hospital, outpatient or emergency department) is shared between a physician and an NPP from the same group practice, and the physician provides and documents the provision of any face-to-face portion of the E/M with the patient; the service may be billed under either the physician's or the NPP's number. The visit is combined and each provider documents his or her portion. However, if there was no documented face-to-face service between the patient and the physician, then the service is only billed under the NPP. Critical care may not be billed as a split/shared service.
Q14. If we have a NPP providing coverage for one of our group providers and he/she has to perform additional critical care during that time, can they bill CPT 99292?
A14. When a qualified NPP within a group provides "staff coverage "or "follow- up" for a physician after the full covered period of time of critical care services claimed by the physician on the same calendar date, the subsequent time by the "covering" NPP is billed using CPT critical care add-on code 99292. The NPP's NPI number is reported on the claim. The services will be paid at the NPP's
fee schedule rate.
Q15. What happens if the critical care services extend over the midnight hour into another calendar day?
A15. CPT coding principles require that when a time-dependent service is performed continuously and crosses over midnight the time should be accrued for, and reported as occurring, on the pre-midnight date; however, once the service is disrupted (i.e., becomes non-continuous), that creates the need for a new initial service on the post-midnight date.
Q16. If a nurse performs CPR (non-bundled) for 30 minutes and the entire time spent with the patient is 45 minutes, is it appropriate for us to bill CPT 99291 or just the CPR since the physician did not perform the CPR?
A16. Critical care is not an" incident to" service and critical care criteria must be met. 45 minutes minus the 30 minutes of CPR does not meet the time criteria of 30 to 74 minutes. Such time spent beyond that associated with the CPR service would be billed with an appropriate level of E/M.
Q17. Is it appropriate for critical care to be billed if a patient is receiving infusions of sodium chloride, at a greater that normal concentration, with the need to be monitored as they would be at risk of medical complications, which could lead to organ system failure?
A17. No, the criteria outlined in CPT both for the patient's clinical situation and for the nature of the services being provided must be met.
Q18. When a physician providing critical care is conferring with providers from another clinic, would that be included in the critical care time?
A18. Necessary time a physician is consulting with another physician regarding the care being provided to the critical care patient would be appropriate to include. The duration of critical care services that the physician should report is time actually spent in necessary evaluation and management, while remaining immediately available to the patient.
Q19. Can critical care time be billed outside the Intensive Care Unit (ICU)?
A19. Yes. Critical care is based on the nature of the services and the patient condition, not patient location. If the critical care requirements are met, care provided outside of the ICU can be billed as critical care. Conversely, just because the patient is in an ICU or CCU does not make the patient critically ill nor cause the services provided to be defined as critical care.
Q20. If a teaching physician is performing critical care, at the same time, in the presence of a resident, is it possible to bill for critical care if the teaching provider is actually doing critical care work?
A20. It depends. Only time spent performing critical care activities by the teaching physician may be counted toward critical care time. Time involved in activities that do not directly contribute to the treatment of the critically ill or injured patient may not be counted towards the critical care time, even when they are performed in the critical care unit at a patient's bedside.
Time spent by the resident (i.e., performing critical care activities in the absence of the teaching physician's direct presence and documented personal involvement) cannot be counted toward critical care time.
Q21. A cardiologist and pulmonologist, from our group, were called to see an inpatient. Both of the providers saw the patient and during that visit, both performed critical care; are both services billable?
A21. Not for the exact same time period. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. For example, if a cardiologist and a pulmonologist are group partners and the critical care services of each are medically necessary and not duplicative, the critical care services may be reported by each regardless of their group practice relationship, as long as they are for different periods of time. Only one physician may bill for critical care at a time. Other physicians in attendance during this time may bill an applicable inpatient E/M code.
Q22. We have an NP whose notes must be approved by a physician. Is is acceptable for the physician to write his notes on a separate page or can he/she insert notes into the NPs notes? If he/she does insert notes, are those notes still considered to be separate notes so he/she can claim the critical care time?
A22. Shared services or "incident to" are not allowable for critical care. The services you have described would be billed by the NP under the NP's NPI, assuming all other criteria for the services have been met.
- Medicare Learning Network (MLN) Matters MM5993 Critical Care Visits and Neonatal Intensive Care (Codes 99291-99292)
- CMS Evaluation and Management Services Guide
- CPT 2015 Standard Edition available from American Medical Association (AMA) online bookstore
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Publication 100-04, Chapter 12, and Section 30.6.12
- IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, section 60-60.4 Incident to Services
Last Updated August 2014.
Q1. When all three key components are not present on initial inpatient visits, would it be appropriate to bill a subsequent inpatient visit?
A1. If a reported code is for the provider's first E/M service to the inpatient during the hospital stay, providers may submit a subsequent hospital care CPT code (99231 or 99232) when the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected).
Q2. If a patient goes to the doctor's office for an office visit and then later the same doctor admits the patient to observation, is it appropriate for him to bill for the initial?
A2. A provider may only bill one E/M per day on a patient. Information from the previous visit may be combined if relevant to possibly substantiate a higher level code.
Q3. If the documentation for CPT Code 99218 does not meet the lowest level of specificity, we were told to use CPT code 99499 and enter a brief description in Item 19 of the CMS 1500 form. What verbiage is required to process this type of claim?
A3. The Internet Only Manual (IOM), Publication 100-04, Chapter 12, Section 30.6 states "Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors expect reporting under these circumstances to be unusual."
Q4. Is there a dollar amount associated with the CPT code 99499?
A4. There is not a fee scheduled (MPFS) amount assigned to this code, it is usually based on the code that the reviewer deems the documentation warrants.
Q5. If Noridian audits by medical necessity, and all key components are not met, would it still be appropriate to bill a high level of service ( i.e. admit CPT code 99222 ) if past family and/or social history (PFSH) are not documented?
A5. Noridian is still bound by CMS regulations to ensure all key elements are met however; CMS also states that medical necessity is the overarching criteria in determining payment.
Q6. If one of the established patient E/M components is missing, (history, exam or medical decision making (MDM), is the documentation still billable?
A6. Yes, it is still billable but, if one of those components is missing the medical necessity of the service which is the overarching criterion may not be met.
Q7. If there has not been a face to face patient visit; however, a reading of a diagnostic test was done by one of our physicians in the ER, can we bill a new patient visit when the patient comes into our office for a follow up?
A7. A new patient visit maybe billed if no face to face visit has taken place by the provider or provider of the same specialty of a group within three years. The level would be based on the documentation and medical necessity of the visit.
Q8. For an established patient visit, physician reads the patient's PFSH to refresh his memory without verifying the PFSH with the patient; He asks "Anything new?" to which the patient responds, "No." If the MD references the prior note with PFSH, may we count PFSH for the review of systems (ROS)?
A8. The PFSH may be counted if it is relevant to the reason for the visit and yes, reporting "unchanged" is appropriate, if medically necessary for the issue being treated/reason for visit. If notes are requested, send the records with the old PFSH.
Q9. For billing out initial observation codes are there any requirements on who can bill?
A9. The physician who orders the patient to observation is the physician who should bill for the observation code(s).
Q10. If the primary care provider (PCP) states that the patient needs to be admitted as an inpatient and contacts the hospitalist (who is not in the same practice) to admit the patient, then sees the patient the next day, can an initial inpatient code be billed?
A10. A subsequent visit code would be appropriate code as the hospitalist took over the admission and care of the patient.
Q11. What does "prescription drug management" consist of? For example, if a provider prescribes Motrin 800mg or a course of antibiotics, would this be considered "Prescription drug management" within the MDM?
A11. Prescription drug management is for managing the drug regimen. This is not just a listing the patient's medications. It is for new drugs prescribed, evaluation and raise or lower drug dosages, etc.
Q12. Do you need to append the modifier 25 on CPT code 99215 with prolonged service as the second code?
Q13. If we have physician documentation saying greater than 60 minutes on this inpatient discharge, can we bill an E/M + prolonged instead of 99239?
A13.If it is a discharge, the code that best describes the service should be billed. In this case, 99239, which is for discharge >30 minutes.
Q14. What is Noridian's position on separate E/M billed with Medicare's annual wellness visit, when providers are also addressing chronic conditions that are stable and/or only labs are being ordered or RXs renewed?
A14. AWV has been addressed in the CMS manuals. An E/M can be billed with modifier 25. Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the Initial Patient Physical Exam (IPPE) or AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service. Be sure to carve out any routine services (99387/99397) and bill separately.
Q15. When billing by time, do we have to state more than 50% of the time was spent when no exam was performed?
A15. Yes and if counseling was a dominant portion of the visit, documentation must state what was counseled, the patient's response(s) and any additional information pertinent to the visit.
Q16. An E/M was completed by our cardiologist, who after performing a pace maker placement had to perform critical care which was denied. Is a modifier 25 necessary on the CPT code 99291?
A16. In this scenario, the modifier 25 would be necessary on the 99291. If the critical care was directly related and in the same global period as the procedure, there would be no additional payment.
Q17. If family history is noncontributory to the acute problem and is not asked by the physician, may we count "family hx = noncontributory" as family history towards ROS?
A17. No, if not inquired about and if it has nothing to do with the chief complaint, family history would not be counted.
Q18. If a 10 point ROS is negative except in HPI, is this an acceptable statement for a comprehensive ROS even though we do not know which systems were reviewed?
A18. A complete ROS inquiries about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. A provider must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, a provider must individually document at least ten systems. See CMS Evaluation and Management Services guide for more information on this topic. (Answer updated 11/7/17).
Q19. Can you explain split share E/M billing?
A19. When a hospital E/M (inpatient/hospital, outpatient or emergency department) is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M with the patient, the service may be billed under either the physician's or the NPP's number. The visit is combined and each provider documents their portion. If there was no face-to-face encounter between the patient and the physician, then the service may only be billed under the NPP. Critical care cannot be billed as a split shared service.
Q20. Where are the face-to-face visit documentation guidelines for shared service between a physician and an NPP?
A20. Guidelines regarding split/shared visits can be found within the CMS Internet-only manual (IOM), Publication 100-04 Medicare Claims Processing Manual, Chapter 12, and Section 30 .
Q21. If our PA performs most of the visit but the physician does step in and also sees the patient and documents it, should we still bill under the PA or are we to bill as "incident to" under the physician's NPI?
A21. If the criterion for" incident to" has been met the PA's services may be billed under the supervising provider's NPI. "Incident to" should not be confused with split share E/M billing.
Q22. If a PA is seeing a new patient and is billing under their own NPI, would it still be considered "incident to?"
A22. No, PAs can bill under their NPI in the clinic setting and see new patients as long as it is not an "incident to" setting. The criteria for a new patient visit must be met.
Q23. In 1997 Documentation Guidelines for Evaluation and Management Services, three chronic conditions can be used for HPI but can it be used for 1995 Documentation Guidelines for Evaluation and Management Services?
A23. This is true only for the 1997 Documentation Guidelines for Evaluation and Management Services. It must give an overview of each condition since the patient was last seen and each condition would then need some kind of ongoing treatment.
Q24. We have several specialty physicians in our group such as an Oncologist, Pulmonologist and a Family Care physician. If the same patient comes to the Pulmonologist and then is seen by our Oncologist several days later, can we bill a new E/M for both specialty physicians?
A24. Yes, as long as the physician or anyone else with the same specialty within the group hasn't seen the patient in the past three years.
Q25. If the record review summary is intermixed with the HPI and not separately labeled as a record review, are we able to count the record review and the elements of HPI obtained?
A25. The same documentation/entry in the notes may not be counted in two areas. The same statement cannot be used as an example for HPI and ROS, just one or the other. The HPI as a reminder is reviewing elements related to the chief complaint.
Q26. In regards to MDM and the number of diagnosis and treatment options, clarify "New problem to examiner." Is the "examiner" each individual provider or group?
A26. If the examiner (provider) is in a group practice, then the new problem would be to the group.
Q27. If patient is referred to observation and discharged after 8 hrs and before 24 hours, does the doctor have to see the patient twice, 8 hrs apart before we can bill 99234–99236?
A27. These codes are for observation or inpatient care with admit and discharge on the same day. The CPT book does not note that two visits are needed. If the physician admits the patient, they would need to be evaluated in order to know if discharge is appropriate.
Q28. If an orthopedic surgeon does an E/M in the ED and a decision for surgery (90 day global) is made, is it appropriate to appended the modifier 57 to the E/M?
A28. Modifier 57 may be appended to indicate the decision for surgery (on a 90 day global procedure) and only if the 90 day global surgery is going to be done on that day or the next day.
Q29. If a patient has multiple stable problems, can each one be counted in the MDM as the number of diagnosis and treatment options?
A29. Only count what is actually being treated.
Q30. What does Noridian consider to be a cloned E/M note? If a note is very similar from day to day but is accurate to what happened, is this a cloned note?
A30. In general, if only the DOS and vital signs are different, then Noridian would most likely consider it cloned. We do realize that there may not be changes day to day detail the stability of the patient but it is important to include the details in the documentation. Medical necessity is also important here. To repeat a family and social history on visits every week or two would be considered cloning or at least not reasonable and necessary.
Q31. Each of our outpatient hospital clinics are not required to use the same E/M guidelines? Cardiology can use 1995 Documentation Guidelines for Evaluation and Management Services and Oncology can use 1997 Documentation Guidelines for Evaluation and Management Services.
A31. Each physician can use which ever guidelines are the most appropriate for the encounter they may use either the 1995 or 1997; however, they cannot combine the guidelines for a single visit.
Q32. For G0101, if it is notated that the patient has a surgically absent cervix, ovaries, is it appropriate for us to count those as part of the seven required elements?
A32. No, we have clarified this with our CMDs and all elements must be performed in order to bill these G screening codes.
Q33. If someone other than a physician collects the history of present illness (HPI), documents it and then the physician reiterates the HPI with the patient, can the physician refer to the other person's documentation with the notation, "I re-obtained the HPI, reviewed the documentation and agree?"
A33. The HPI must be done and individually documented by the physician.
Q34. An RN or NP obtained the HPI and documents it. The physician then goes over the information with the patient to verify it, can the MD say, "I verified the HPI with the patient. Please see RN/NP documentation above?"
A34. If that scenario takes place, the information will not be accepted if reviewed. The MD must gather and document the HPI themselves. The ROS and PFSH can be recorded by other staff and the physician then reviews and confirms the information.
Q35. We see that some providers document their record review within the HPI without labeling it as such. Is it okay to count both the record review and HPI elements if we do not use the same info for both?
A35. The information may only be counted once either HPI or ROS.
Q36. When we are submitting in house lab bills for PT/INR which code is preferred the main reason for the anticoagulant or the secondary diagnosis code V58.61?
A36. The V code and the code for diagnosis of the patient, such as atrial fibrillation may both be on the claim. It doesn't matter which one is first.
Q37. Does Medicare recognize specialty 50 (nurse practitioner) as a separate specialty? If so, are they able to bill for a new patient office visit, if another physician of a different specialty in the same group also saw the patient?
A37. An NP, specialty 50, is recognized as a separate specialty. The NP should reserve the new patient E/M codes when seeing a patient for a new health problem on behalf of the physician. If the NP is seeing the patient for a health problem that another practice provider (general, primary or internist) in the same group was previously seen for a subsequent visit, would be more appropriate.
Q38. What are the CMS rules regarding amending or adding information to an existing record?
A38. Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service. Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must clearly and permanently identify any amendment, correction or delayed entry, indicate the date and author of any amendment, correction or delayed entry and not delete but instead clearly identify all original content.
Providers will find more information at the following sources.
- CMS Evaluation and Management Services Guide
- IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, and Section 30.6.12
- IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60-60.4 "Incident to Services"
- IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 22.214.171.124 "Amendments, Corrections and Delayed Entries in Medical"
New Patient vs. Established Patient Visit
Last Updated October 2017
Q1. A new patient comes into the clinic for a preventive visit (CPT 99385) or an Annual Wellness Visit (AWV) (HCPCS G0439). During this visit, the provider documents and treats additional problems to merit an additional evaluation and management (E/M) visit. Is this a new or established patient visit?
A1. When a physician furnishes a covered visit at the same time as a noncovered preventive visit (CPTs 99381-99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. The physician may charge the patient a charge for the noncovered remainder of the service, which is the amount the physician's current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. When a significant, separately identifiable, medically necessary E/M service along with the AWV is furnished, Medicare may pay for the additional service when modifier 25 is appended to the appropriate level E/M code.
Q2. Dr. A and Dr. B are of the same specialty in the same group practice. The patient was seen by Dr. A, but never by Dr. B. Dr. B left the group practice and is now at another clinic. The patient decided to see Dr. B at his new practice. Is this a new or established patient to Dr. B?
A2. Since this patient was never seen by Dr. B, this is a new patient visit for Dr. B.
Q3. What determines a group practice of same specialist? Is it the group National Provider Identifier (NPI) or the specialty clinic?
A3. A group practice is determined by their group NPI for billing purposes. Additionally, individuals providing the same specialty services within a clinic are considered "same specialty" even when the Medicare specialty identifier may be distinct. For example, a patient seeing a Family Practice physician for a condition one visit does not become a "new patient" when an internist or Nurse Practitioner (NP), who is cross covering (i.e. where there has been no medical necessity for a separate specialty), sees him/her for a follow-up visit for the same condition.
Q4. Does the same mid-level rule apply to a Physician Assistant (PA) and a NP? Does the location of the service matter, (e.g., inpatient hospital then at the office)?
A4. Yes. A PA is a specialty 97. If a PA sees a patient and bills for an initial visit, another PA within another specialty department of the same clinic may see the same patient but will bill the visit as an established patient. The location in which the patient is seen is not a factor.
Q5. A neurologist interprets a sleep study and follows up with the new patient in the clinic. At the time of the clinic visit, is it a new or established patient visit?
A5. Unless the neurologist was present during the sleep study and billed for a service that has a face-to-face component, it is a new patient visit.
Q6. Is a nerve conduction study performed by the physician considered a face-to-face visit?
A6. Yes. The physician is conducting the nerve conduction study on a face-to-face basis.
Q7. A PA sees a patient for an initial visit in an orthopedic office. Two weeks later, the patient sees a physician. Is the second visit, provided by the physician, an initial new patient visit?
A7. No. Since the PA and the physician are both in the same specialty department, this is an established patient visit.
Q8. A patient has a return visit to the same physician for a different complaint, different body part or injury date. Is this a new or established patient visit?
A8. If occurring within three years, it is an established patient visit. A new problem or complaint is not a factor in determining whether a patient is new or established.
Q9. A patient sees an optometrist one day, and later sees a Medical Doctor (MD) in the same office group. Is this a new or established patient visit for the MD?
A9. Assuming there is documented medical necessity for the independent visit, this is a new patient visit for the MD.
Q10. A neurologist and a neurosurgeon are in different clinics, but are under the same group NPI. If both see the same patient, can each bill a new patient visit?
A10. Yes, if one is not merely cross-covering for the other; the determining factor is the medical necessary specialty of the physicians.
Q11. An established patient to a family practice physician comes in and sees an NP. Is this visit a new patient visit as the specialty is different from the physician?
A11. No. Since the NP and the physician are in the same practice, this is still an established patient visit.
Q12. Before seeing the physician for the first time, a patient goes in for lab tests. Does the visit to the lab count as a face-to-face visit?
Q13. A physician bills for a surgical procedure; the history and physical are included in the procedure. If the patient is seen again by the same physician, will it be for a new or established patient visit?
A13. If occurring within three years, it will be an established patient; however, depending on the post-operative period of the surgical procedure, (0, 10, or 90 days), the visit might be included in the global days and not billable.
Q14. In a multispecialty clinic, a new patient sees a PA in the orthopedic department and then sees another PA in the cardiology department. Is the visit by the PA in cardiology a new patient visit?
A14. Since both are PAs (specialty 97), they are of the same specialty in that group. Where they are practicing is not a factor in determining new or established patient for different non-physician practitioners.
Q15. A provider is an assistant at surgery and a year later sees the same patient for a different problem. Is this considered a new patient? The patient did not see the assistant surgeon prior to surgery.
A15. No. The visit will be for an established patient visit. The assistant surgeon saw the patient during surgery.
Q16. A patient was seen exactly three years ago to the day, is the visit new or established? For example, he/she was last seen March 17, 2014 and is seen again on March 17, 2017.
A16. The distinction comes directly from CPT: "A new patient is one who has not received any professional services from the physician/qualified healthcare professional or another physician/healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years." Since the question indicates a full three years have elapsed, this will be a new patient visit.
Q17. The patient was seen by a pediatric neurologist last year and will now be seen by an adult neurologist. Since both have different taxonomies, will this be a new patient for the adult neurologist?
A17. The deciding factor whether a patient is new or established is based on the specialty of the physician. Since pediatric neurology is a specialty 37 and adult neurology is a specialty 13, he/she will be a new patient for the adult neurologist assuming there is a medical necessity for the second neurologist's visit and he/she is not cross-covering for the first.
Q18. A patient was seen in Prompt Care at the hospital. Using the same physicians, we opened a clinic across the street from the hospital. If the patients are seen at both facilities, are they considered established patients?
A18. Yes, if a patient has been seen within the last three years by a physician of the same specialty.
Q19. When providers practice out of the same office, will different subspecialties (electrosphysiology, cardiology and interventionalist) bill a new or established patient visit?
A19. Electrophysiology (21), cardiology (06) and interventional cardiology (C3) have different specialty codes. Assuming there is a medical necessity for the specific subspecialty and he/she is seen for the first time, a new patient visit should be billed.
Updated December 2017
Q1. Is a patient required to be seen for the face-to-face visit on exactly the 7th or 14th day after discharge?
A1. The criteria for a TCM service is for the patient to be seen within the 7th or 14th day depending on the complexity.
Q2. Can a provider still bill for a TCM if a call was made on the 2nd day after discharge, was seen within the 7th day for high complexity but was readmitted before the 30th day and was discharged two days later?
A2. Yes. As long as the coordination of care is documented to have continued for the full 30 days or providers may choose to change the billing of the original episode to a regular E/M and bill as episode of TCM care following the second admission. The latter might be more beneficial for the patient.
Q3. Is the staff member making the 2nd day interactive phone call required to be under the direct employment and supervision of the billing provider or can this staff member just be employed by the organization or clinic?
A3. The staff member must be a licensed health care professional acting within the scope of their license and reporting to the provider who is going to perform the transitional care visit. If the physician is employed by a facility, the licensed health care professional making the call must be employed in the same outpatient clinic in which the physician provides outpatient services and is in a collaborative reporting relationship.
Q4. If a patient is discharged from the hospital and is going to a rehab facility, is it appropriate for TCM to be billed?
A4. No. Rehab facilities have skilled nursing; therefore, TCM services cannot be billed.
Q5. Can a surgeon bill for TCM if it is not within the global period?
A5. If a surgeon discharged a patient from the hospital after surgery, this period would normally still be in the global period. TCM services are usually done by the attending physician overseeing the patient's medical condition.
Q6. Is the patient's complexity (moderate or high) determined by the discharging physician or the physician seeing the patient at the TCM visit?
A6. The complexity of a patient is usually determined to be the same by either physician.
Q7. A provider sees a patient on day six. Should the date of service be the date of day seven or date of service on day six?
A7. Date of service is the date the patient is seen. In this case, day six.
Q8. Can the second day communication call be done on the same day of discharge?
A8. No, it cannot be on the day of discharge. Communication with the patient or caregiver must be completed within two business days after discharge, with the first business day after discharge being day one.
Q9. Can a resident physician provide the TCM face-to-face visit?
A9. Residents may render this service while the teaching physician bills for the service. These CPT codes (99495 and 99496) are subject to the same teaching physician rules as any other E/M service. TCM does not fall under the Primary Care exception for teaching physicians. In the teaching billing context, append the GC modifier and be sure all criteria are met per the CMS IOM, Publication 100-04, Chapter 12, Section 100.1-100.1.6 .
Q10. Can a provider report TCM if the patient is discharged from an Emergency Department?
Q11. A patient contacts their provider before the second day communication call is made. Does this count for interactive contact if the call is within two days of discharge?
A11. Yes, if all the TCM requirements are met during that call.
Q12. What code should be reported if the physician did not see the patient on or within the 14th day?
A12 Since not all the requirements were met, TCM cannot be billed. A provider can bill using an appropriate E/M code if seen after the 14th day.
Q13. Is the documentation regarding the discharge date required to be within the chart notes of the face-to-face visit or just within the patient's records itself?
A13. The discharge visit must be a face-to-face visit with the patient and the documentation should be kept in the patient's chart.
Q14. After hospitalization, is a patient required to return to the same community setting he/she came from (e.g. home to hospital then back home), or can he/she go to an assisted living facility upon discharge?
A14. He/she is not required to return home but instead can go to an assisted living facility as long as it is not a Skilled Nursing Facility (SNF).
Q15. How does a provider count the days after discharge for the 2nd day communication and the 7th or 14th day visit?
A15. The second day communication is the second day following the discharge date, the day after the discharge date being day one while the seventh or 14th day visit is counted from discharge, the discharge date being day one.
Q16. Can a provider bill TCM with Chronic Care Management (CCM)?
A16. If the TCM service period ends before the end of a given calendar month, at least 20 minutes of qualifying CCM services are subsequently provided during that month, and all other CCM billing requirements are met, CCM can be billed during the same calendar month as TCM only. However, we expect, most of the time, CCM and TCM will not be billed during the same calendar month.
Q17. Can the same provider bill an E/M visit on the same day with modifier 25, for an unrelated problem?
A17. No. Only CPT codes 99495 or 99496 should be billed. It should compensate for all conditions the patient is being seen for.
Q18. If a patient is put on home health during the 30 days following TCM, can a provider still bill for the TCM?
A18. No, this cannot be billed.
Q19. What should a provider do if their claims are being denied because the hospital hasn't billed for the hospital stay yet?
A19. Contact and work with the hospital to ensure a claim would be filed timely.
Q20. Can any provider specialty bill for TCM services?
A20. Physicians of any specialty including non-physician practitioners (NPP), (Nurse Practitioner (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS) and Clinical Nurse Midwife (CNM)) can oversee management and coordination of services, as necessary, for all medical conditions, psychosocial needs and activity of daily living support for the full 50-day post discharge.
Q21. If "incident to" rules are not allowed for Place Of Service (POS) 22 and the clinic is provider based and bills with POS 22, how does a provider handle the incident to rules for NPPs preforming TCM?
A21. Incident to rules do not apply in this situation. Medicare has at least two separate definitions of a physician. For purpose of TCM service, the broader definition applies with MD, DO, DPM, NP, PA or CNS acting within their scope of practice in the state in which they are licensed.
Q22. If a patient is discharged from a SNF, can the TCM rules apply?
A22. Yes, if the patient is discharged to one of the community settings, like the patient's home.
Q23. If the face-to-face visit happens on the first or second day after discharge, can that double as the second day communication and the face-to-face visit?
A23. Yes, if all criteria are met.
Last Updated Dec 20, 2017