ACM B Questions and Answers - April 10, 2024


Q1. For Evaluation and Management (E/M) documentation, when a patient has comorbidities (e.g., COPD), must a provider state how or why the condition may complicate surgery that requires anesthesia or identify condition as a patient risk factor? Are there plans to audit with this depth of scrutiny? Is provider documentation burden considered?
A1. If the COPD would be a risk to the patient for the planned surgery with anesthesia, the documentation should indicate the reason for the risk to support the medical necessity of billing for a higher-level E/M service.

The level of service billed would need to be supported by the medical record. Not all COPD patients may be at a higher risk, depending on the status of their COPD, controlled or not, complications could be a factor.

Q2. When documentation does not indicate condition is chronic for Gastroesophageal reflux disease (GERD), would a Medicare auditor consider the condition stable? GERD is usually chronic, does the provider need to state "chronic GERD-stable" when the problem is clearly addressed?
A2. Each patient's GERD condition may be different, depending on other factors, comorbidities, age of patient, medications, etc. The documentation would need to support the status of the patient during the current encounter and if GERD were treated or considered. The statement of 'Chronic GERD-stable' would help to provide the status of the patient if that is determined. Each GERD patient may be different and templated language in all GERD patient's medical records may raise a concern.

Q3. When documentation supports time-based coding for E/M services, and time indicates "Approximately 35-40 minutes" for E/M activities related to the patient on date of service, would it be appropriate to choose the code based on 35 minutes?
A3. Timed documentation may be used to determine the level of E/M. The office E/M codes have time indicated that they were met or exceeded. The 35-40 minutes would not allow the higher level of E/M code to be used as the description indicates time met or exceeded. CPTs 99203 = 30 minutes, 99204 = 45 minutes, 99214 = 30 minutes and 99215 = 40 minutes and time indicating "approximately", when time may not have met or exceeded the 40 minutes.

Q4. Is a signature required to be dated the same date as the encounter?
A4. Yes. It is not acceptable to add late signatures to orders or medical records (beyond the short delay that happens during the transcription process). When an undated entry is received, and if it can be determined by previous dated entries, immediately above and below, medical review may assume the entry date in question.

Complying with Medicare Signature Requirements 905364 and CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section

Q5. Would the risk of management options be High if an MD documents that the patient is on a drug that requires intensive monitoring for toxicity, but the MD is not the one prescribing or managing the drug or the condition that is being treated with the drug? The MD is seeing the patient for a separate condition.
A5. From CPT 2024 E/M guidelines: For the purpose of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of reported encounter.

If the condition and the drug is not being monitored or managed by the MD, documentation should support the appropriate level of MDM and related risk associated with the current encounter and problem(s) addressed. Without documentation, regarding consideration of drug interactions by the physician treating the hypertension, this would not be considered high risk management.

Q6. Our patients receive Trigger Point Injections (TPIs) for myalgia in the lower back and a greater Occipital Nerve block for occipital neuralgia in the office. Does this only apply when it's performed in a surgery center with an epidural steroid injection (ESI), Facet, etc.?
A6. Yes. This limitation would apply in all settings and not just a surgery center. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks, etc.) during the same session as TPI.

Q7. If a patient has received Trigger Point Injections prior to April 1, 2024, will these count toward their "no more than three trigger point injections per year" total for the next rolling 12 months?
A7. No. The new April 1, 2024 policy starts on that date of 12 rolling months for the first injections and going forward.

Q8. Are telehealth visits billed with place of service (POS) 10 supposed to be paying less than POS 11 (office) in-person visits? If not, is this being fixed in the payment system?
A8. No. Noridian has implemented a mass adjustment that began 3/15/2024, to reprocess claims that were paid incorrectly for the POS 10. Always check our home page "ALERTS" section for these types of issues. This was reported 1/29/2024 and under "POS 10 Pricing at Facility Rate".

Q9. The LCD for Facet Injections and Epidural Steroid Injections (ESI) appear to be in conflict when billing for cyst aspiration and transforaminal ESI with CPTs 64493 and 64483. Prior authorization (PA) is required for 64493 when performing medial branch blocks (MBB), but that isn't what we are documenting, which denies the PA due to medical necessity. The cyst aspiration and MBB are billed with the same code. How can we have the cyst aspiration procedure paid?
A9. The Facet Joint Interventions for Pain Management LCD has recently completed a comment period on March 2, 2024, as the LCD is being revised. The medical directors are now reviewing all comments received to make any necessary revisions. The draft version can be viewed on the CMS Coverage Database under:

JE Proposed LCD - Facet Joint Interventions for Pain Management (DL38801)

JF Proposed LCD - Facet Joint Interventions for Pain Management (DL38803)

Q10. Local Coverage Article A57327 and LCD L37283 references electrocardiograms. Where can I find coverage for a specific diagnosis for echo add-on CPT 93319?
A10. Per Medical Policy, the electrocardiogram article has been updated to remove the 93319 (still shows as of April 2024) and there is no LCD that specifically covers transthoracic echocardiograms. This information was updated March 21, 2024 and is viewable in the Medicare Coverage Database (MCD) as of Thursday, March 28, 2024.

Q11a. Inpatients at a rehab facility or nursing facility seen at a Part B provider office for an unrelated condition, would the office visit be billed as 99203 or 99213 with POS 31 or 32?
A11a. No, the POS would be the office where the patient is seen. If they are listed as an inpatient, the provider should see that patient at that facility. If the patient is not an inpatient at a Part A stay (such as nursing facility vs SNF), then the patient could be brought to the office and billed as POS 11.

Q11b. What about if x-rays are performed?
A11b. If it is a Part A inpatient stay, only the professional component can be billed to Part B. The CMS Skilled Nursing Facility (SNF) Consolidated Billing requirement bundles care provided to residents during a covered Part A SNF stay. Exception: There are a limited number of services specifically excluded and separately payable. The answer depends on where the patient is located and if it's a Part A stay.

Q11c. Is that solely the inpatient facility's responsibility and would this change if the condition is related to the patient's inpatient stay?
A11c. If it is a Part A stay and no, the condition does not change the responsibility. POS is determined by where the patient is and if there are other services like supplies or equipment brought in, they may fall under Consolidated billing.

Q11d. As an orthopedic office, we receive requests from facilities to evaluate and treat inpatients. Some patients are on hospice, and we can append modifiers GV or GW, others are not terminal. We are told to bill Part B and we receive denials. Do we ask the facility for reimbursement?
A11d. This would depend on if the patient is in a Part A stay at the facility and the services that are billed.

Q12. When a patient arrives for a scheduled chemotherapy and a physician performs a detailed exam (including lab review for drug toxicity) can the physician bill an E/M service since the hospital bills for the chemo administration? The physician is not an employee of the hospital.
A12. No. It is appropriate to bill an E/M service on the same day as a drug administration code when documentation clearly supports a medically necessary E/M service unrelated to the chemotherapy administration.

This may include a physician or NPP evaluation and management of the disease process requiring the administration for the drug, if an alteration of the treatment plan may be required, due to symptoms or signs, adverse treatment reactions, etc.

A routine interval evaluation to assure there are no new issues, when the patient presents for chemotherapy, may not be separately paid by Medicare, and must not be billed.

Q13. Are surveillance mammograms, for asymptomatic patients with history of breast cancer who are >5 years post treatment, considered screening or diagnostic?
A13. Per NCD 220.4:

  • Medicare does not have a specific policy with mammography coverage for an asymptomatic person with a history of breast cancer. CMS allows the attending physician to decide the appropriate procedure for the patient.
  • A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy - proven benign breast disease and includes a physician's interpretation of the results of the procedure.
  • A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician's interpretation of the results of the procedure.
  • Z12.31 should be the primary diagnosis code when ordering a screening mammogram.

Q14. Is Home Infusion Therapy (HIT) paid per hour, per visit, or per 15-minute increment?
A14. HIT payment is based on five hours of infusion therapy; regardless of the actual visit length. Bill your actual G-code time in 15-minute increments. E.g., 106 minutes, falls in the range of 98 minutes to <113 minutes = 7 units.

Q15. When a chaperone is in the exam room for a pelvic exam that was not completed, can we still bill CPT +99459?
A15. Depends. This add-on code was established to capture the additional required resources during a pelvic exam, as part of the service for those that require pelvic examinations. Medical documentation would need to support that a pelvic exam was performed. +99459 should not be added to every female medical exam without the proper documentation. Code is billed ONLY with E/M CPTs, 99202-99205 or 99212-99215.

Q16. Is time required to be documented for hospital discharge CPTs 99238 (30 minutes or less) and 99239 (more than 30 minutes)? If provider documents 30 minutes, does that support?
A16. No. CPT 99238 does not include a minimum time requirement, so documentation of 30 minutes or less would only meet 99238. However, CPT 99239, has a minimum time requirement of 30 minutes or more, so time notation is a requirement to indicate either start and stop times or total minutes.

Q17. Since G2211 is included on the CMS telehealth list and can be satisfied by an audio-only interaction, can it be billed with E/M phone codes 99441-99443, rather than 99212-99215 for established patients?
A17. No. HCPCS +G2211 (add-on complexity) may only be billed with office and outpatient E/M codes (99202-99215). G2211 cannot be billed if the E/M has modifier 25 appended for E/M CPTs. This was effective January 1, 2024, and read more at CMS Change Request (CR) 13272-E/M Complexity +G2211.pdf.

Q18. We have several denials under N115 (noncovered services as not deemed medically necessary) stating that CPT 77002 and G0260 cannot be billed together. What can we do when we've called Noridian multiple times and told G0260 will deny if billed without 77002 or 77012?
A18. You're correct that G0260 (sacroiliac joint injection) and CPT 77002 (fluoroscopy) are allowed together per the National Correct Coding Initiative (NCCI) edits. Indicator 1 shows G0260 77002 20120101 *, where modifier 59 is appended to 77002.

However, per Noridian's Local Coverage Article (LCA) Billing and Coding: Sacroiliac Joint Injections and Procedures (A59246), revised 1/25/2024, "The medical record must contain documentation that fluoroscopic guidance or CT guidance (77002 or 77012) was used with HCPCS code G0260" and packaged into G0260.

If using fluoroscopy for other imaging performed on the same day, then modifier 59 could be appended. No separate payment is made to the ASC (POS 24) or Outpatient Prospective Payment System (OPPS) hospital outpatient department for 77002 and 77012.

In January, Noridian had an alert and mass adjustments completed.

Q19. Does a Transcatheter Aortic Valve Replacement (TAVR) require separate documentation from the cardiologist and cardiovascular surgeon? Or can the cardiologist document the work of both co-surgeons?
A19. Both must document. Many providers are supplying either one independent evaluation performed by one cardiac surgeon, or two independent evaluations performed by the same surgeon. The National Coverage Determination (NCD 20.32) for TAVR, under Indications and Limitations of Coverage states the following:

"Two cardiac surgeons have independently examined the patient face-to-face and evaluated the patient's suitability for open aortic valve replacement (TAVR) surgery; and both surgeons have documented the rationale for their clinical judgment and the rationale is available to the heart team."

To be compliant with this requirement, documentation would include two individual evaluations, performed by two separate cardiac surgeons, and signed.

Q20. Is nail debridement (CPTs 11720 and 11721) documentation of marked limitation of ambulation optional, if a patient is experiencing pain from their mycotic nails?
A20. Documentation is not optional. The treatment of mycotic nails may be covered, when the physician, attending the patient's mycotic condition documents:

Ambulatory patient:

  1. Clinical evidence of mycosis of the toenail, and
  2. Patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

Non-ambulatory patient:

  1. Clinical evidence of mycosis of the toenail, and
  2. Patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

CMS Internet Only Manual (IOM) Publication 100-02, Chapter 15, Section 290.C4

Q21. Will Noridian be recognizing the new times listed in the 2024 CPT book for office visits (99205 and 99215)? Will prolonged services go by the new time as listed on the CPT (99205 60 mins. and 99215 40 mins.)?
A21. In January, Noridian reached out to CMS to verify if the times listed in the 2024 CPT book would change the CMS Internet Only Manual (IOM), 100-04, Chapter 12, Section We were told the time ranges in the IOM would remain unchanged. If planning to submit claims for prolonged services with an E/M code, the IOM time ranges would need to be followed.

Q22. When is it appropriate to code for CPT 94375 (respiratory flow volume loop) vs. 94010 (breathing capacity test-spirometry)? Does 94010 include 94375 that has a higher relative value unit (RVU)?
A22. Yes. CPT 94010 does include 94375 with the higher RVU. You may bill either code alone; just never together. Note: Per the NCCI manual, 2024 Chapter 11, page XI-18: If the provider is performing spirometry, they should bill 94010, which includes 94375.

  1. J. Pulmonary Services CPT coding for pulmonary function tests includes both comprehensive and component codes to accommodate variation among pulmonary function laboratories.
    1. 1. Alternate methods of reporting data obtained during a spirometry or other pulmonary function session shall not be reported separately. For example, the flow volume loop is an alternative method of calculating a standard spirometric parameter. CPT code 94375 is included in standard spirometry (rest and exercise) studies.

Q23a. Telehealth POS 02 or 10 is determined by the location of where the patient is, correct? Would it be POS 02 when the patient is in the nursing home and provider is in their office?
A23a. Yes, the POS is determined where the patient is located. Would the nursing home be the patient's permanent residence? Or is this a skilled nursing facility that is only temporary? Use POS 10 when the patient is in their residence (MLN MM12427).

Q23b. When a provider is licensed in multiple states but only enrolled in one, can the provider bill the Medicare contractor where they are enrolled if telehealth was provided to a patient in another state?
A23b. For Medicare purposes, the provider needs to be licensed and enrolled in Medicare where they are sitting, when they perform telehealth services. States may have other licensing requirements that need to be followed. For the denied claims, it may be how the information is entered and would need to be reviewed.


Q24. How do we code different vaccinations; such as FLU, T-DAP and MMR?
A24. COVID-19, Influenza and Pneumonia vaccine codes and their pricing can be found on the CMS Medicare Part B Drugs and Vaccine Pricing. For example:

  • Vaccines allowed as preventive
    • Influenza, (several CPT 906xx) with G0008 (influenza administration)
    • Pneumonia (several CPTs 907xx) with G0009 (pneumonia administration)
  • CPT 90715 (Tetanus-Diphtheria and Pertussis T-Dap) - only allowed with wound, injury or burn
    • With 90471 or 90472 (administration)
    • Not allowed from Medicare B as preventive or booster
  • Measles, Mumps and Rubella (MMR) only covered by Medicare Part D plans

Read more under Noridian's Browse by Topic, Tetanus and Diphtheria Vaccinations Billing Guidelines

Q25. Can +G2211 complexity be billed with an office visit 99214 and an influenza (G0008) or pneumonia (G0009) administration?
A25. As long as the E/M does not have a modifier 25, you can also bill your vaccine and administration. If you review the National Correct Coding Initiative (NCCI) Policy Manual, Chapter 11. It states when an E/M code is billed with vaccine codes, the E/M code may be reported with modifier 25. This is item number 15 on the bottom of page XI-6 in the 1/1/2024 version. There isn't a bundling edit for this, but it is indicated in the NCCI manual.

  • MM 13473 How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211
  • MM 13272 Revised - Edits to Prevent Payment of G2211 with Office/Outpatient Evaluation and Management Visit and Modifier 25

Q26. Is a formal transfer of care required when a surgeon requests an anesthesiologist with neuro-critical care specialty? Does it require a formal transfer of care if they take over in post-op and then back to the surgeon prior to discharge? Patient is still in the hospital and another provider (not the surgeon) providing post-op care.
A26. When the surgeon does request another physician to perform the post-op care, the medical record would indicate the physician performing the post-op care. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary's medical record.

The surgeon would bill the surgery with the appropriate surgical code and append modifier 54. The physician performing the post-op care portion would bill the same surgery code with modifier 55. Both indicate the number of post-op days, they are responsible for, in item 19 (or electronic equivalent) per CMS IOM Publication 100-04, Chapter 12, Section 40.2.3.

Q27. How do we bill for code T1014 for mental health Telehealth?
A27. This is an invalid code for Medicare and would reject in the system.

Q28. Does Noridian have something regarding documentation, amending records and delayed entries? For example: if the clinician doesn't document at the time services were rendered, when they finally enter the progress note and delayed entry; how should it be distinctly identified?
A28. Records sourced from electronic systems containing amendments, corrections or delayed entries must:

  1. Distinctly identify any amendment, correction, or delayed entry, and
  2. Provide a reliable means to clearly identify the original content, modified content, and the date and authorship of each modification of the record.

Log into the EHR system, with own unique login, and when finished with entry, date and lock that entry with electronic signature, name, credentials, and date.

Noridian's website addresses documentation under Browse by Topic:

JEB: Browse by Topics, Documentation Requirements

JFB: Browse by Topics, Documentation Requirements

Q29. When a provider leaves the critical care or unit to document in the EHR, the location could be in an office, home, or quiet spot for the provider to document with less interruption and distraction. When they're off the floor or unit, would it be permissible for that provider to include the total time for critical time off the floor, off the unit, and bill? It's still showing floor or unit in the IOM.
A29. It does require time by bedside or elsewhere on the floor or unit. If the provider is leaving the facility, going to a different unit or floor, the time is not counted. You can count the time you're completing the medical record if you're on the same floor or bedside. CMS did not make the change to the critical care services. We also recommend reaching out to your specialty society.

Q30. If the MolDX technical assessment test is "not successful", does that automatically render the test 'non-covered'?
A30. Yes. It could mean that the test has not shown its clinical utility and/or is not reasonable and medically necessary for the patient.

Q31a. Is the insulin pump training included and part of Diabetic Self-Management Training (DSMT) with HCPCS G0108 and G0109, or can we bill this separately?
A31a. Not really, as training is not usually included in DSMT. However, when the patient receives the pump from the DME supplier, they would receive training on how to use it from the supplier. Read more under Noridian's Browse by Specialty pages, under Preventive, Diabetic, DSMT and Medical Nutrition Therapy (MNT):

JEB: Browse by Specialty, Preventive, Diabetic, DSMT and MNT

JFB: Browse by Specialty, Preventive, Diabetic, DSMT and MNT

Q31b. If we bill an insulin pump training separately from DSMT, would the Continuous Glucose Monitoring (CGM) codes (95249 or 95250) be used for the training? Would it matter if the patient has the imbedded monitor vs. no imbedded monitor?
A31b. Patient training is included when billing CPT 95249 (patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training and printout of recording) and 95250 (physician or other QHP provided equipment, technical components of CGMs, including patient training, glucose sensor placement, monitor calibration, use of a transmitter, sensor removal, and downloading of data recording printout). The CGM implantable Local Coverage Article (LCA) A58133 is discussed at CMS Medicare Coverage Database (MCD) - LCA A58133. Coding depends on CPTs 0446T, 0447T or 0448T and information included.

Q31c. For CGM 95249 or 95250, does the provider need to document whether the device is patient-owned or clinic provided?
A31c. Yes. There are many initial provisions that must be met in order to have the CGM device covered by Durable Medical Equipment (DME) with HCPCS E2103 (non-adjunctive, non-implanted continuous monitor or receiver). Class II DME (including FreeStyle Libre 2 system and FreeStyle Libre 3 system) does not utilize a modifier. KF modifier does apply to Class III DME (including FreeStyle Libre 14-day system). Documentation requirements:

JA: DME Webinar on Demand

JD: DME Webinar on Demand

Last Updated May 17 , 2024