ACM Questions and Answers - October 11, 2023

Note: 2024 Final Rule released November


Q1. How do we define the difference between minimal versus low risk, as the AMA has not defined the difference? Can over-the-counter (OTC) medications be considered low risk?
A1. The table of risk indicates the level of MDM for low risk may not be part of the assessment selection; however, the use of OTCs for treatment is part of the decision process for the patient. Each patient may be different depending on conditions, age, and other medications. OTC recommendations may or may not be a risk factor. This would depend on dosage changes that differ from packaging instructions and consider patient’s medical status.

The American Medical Association (AMA) has published guidance on determining the level of risk. The risk would be determined by the physician or qualified health care professional based on their evaluation of the patient’s condition.
Source: American Medical Association CPT® Evaluation and Management (E/M) Revisions FAQs.

Q2. When the patient is provided Zofran IV push in the ER for nausea, would this be considered Moderate Risk for the Evaluation and Management (E/M) medical decision-making (MDM)?
A2. Moderate risk could apply, because the patient was being temporarily monitored for the decision results to use the type and dose of medication. Overall, the risk will be determined by the patient’s overall medical status and if the medication risk to the patient would be low or moderate.

Q3. We’ve heard that Medicare and many other payers cannot be billed when a Physician or Advanced care provider (ARNP, PA-C, etc.) meets and consults with a patient’s family and/or caregiver(s) when the patient is not present. Does Medicare allow all E/M services to be reported when the provider only meets with the family or caregiver when the patient is not present?
A3. No. Medicare follows most of the AMA guidelines when counting time for E/M services. The patient would need to be present for the majority of the encounter. Time meeting with the family or caregiver may be counted if medically necessary for the patient’s treatment. When billing based on time, include all time related to the patient on the date of the encounter, when managing the patient’s treatment and discussing with family or caregivers, as that time would count. See Medicare Learning Network (MLN) 006764 Evaluation and Management Services Guide Aug 2023.

Under IOM 100-02, Chapter 15, Section 30.A; Physician Services, General, a service may be considered to be a physician’s service where the physician either examines the patient in person or is able to visualize some aspect of the patient’s condition without the interposition of a third person’s judgment.

Q4. Can a physician bill for chemotherapy education?
A4. No. There is not a billable CPT or HCPCS code and Medicare does not pay separately for chemotherapy education. If performed during the same visit as a chemotherapy infusion, the education would be bundled into the drug infusion code. If there is a separate, medically necessary E/M service performed, chemotherapy education may be factored into the medical decision-making for the time spent on that day. See also Answers 10 and 17.

Q5. Is there a Local Coverage Determination (LCD) available for radiation therapy use in the treatment of benign conditions? Is treating osteoarthritis with external beam radiation therapy (EBRT) considered experimental using HCPCS G6003-G6016?
A5. No. Noridian's External Beam Therapy policy retired in 2016. We are not aware of coverage for benign conditions; however, treating osteoarthritis should be covered. For the conventional EBRT delivery, Medicare will not cover for routine follow-up care during the three months after completion of external beam therapy since this is considered part of the treatment management.

Q6. Our Cardiology practice has denials that another physician was reimbursed. We provided the professional component for some facility-based CPT 93306-26 (Echocardiography). Our redetermination was also unfavorable. How do we prove that there was only one study that day and our provider read?
A6. Hospital claims billed under claim UB04 should be Revenue code 04X or 073X imaging and place of service 22 (hospital outpatient department). If the physician is not working under arrangement for the hospital; in which case both the technical and professional components fall under global services, the hospital is the only entity that can bill for the diagnostic test (which includes interpretation).

Note: During the ACM call, it was incorrectly indicated the hospital should bill with TC modifier. After the call, we discussed with Part A, that stated the hospital should be using the indicated revenue code to allow the professional component to be billed separately.

Q7. Psychiatric Collaborative Care Management (CPT add-on code 99494) has a Medically Unlikely Edit (MUE) of ‘2’ per date of service. Since the code is per month, how can additional time be allowed for complex patients? Would an appeal allow additional time?
A7. An appeal would be allowed with supporting documentation of medically necessary time from the care management team. Review the CMS Medicare Learning Network (MLN) 909432 title "Behavioral Health Integration Services" booklet to verify time is totaled correctly by the care management team.

If a provider believes the MUE value should be modified, email the CMS NCCI mailbox:? Include code(s), an alternative MUE value, the rationale for the alternative MUE value, and any supporting documentation. Do not include any Protected Health Information (PHI).

Q8. Can audio only visits (CPTs 99441-99443) be provided to new and established patients thru the end of 2023 or just established patients after the 05/11/2023 (end of Public Health Emergency-PHE)?
A8. Effective 5/12/2023, these codes will only be allowed for established patients per the CPT code description and guidelines.

Q9. Since there is no policy on how to bill unlisted surgical CPT codes, what is needed in the narrative or comment field in Box 19?
A9. Noridian does address "Unlisted and Not Otherwise Classified (NOC) Code Billing" under Noridian's Browse by Topics, Documentation Requirements. An unlisted CPT must have a "concise description of the procedure" with how procedure performed (e.g., laparoscopic, transnasal, infusion), body area treated and why performed.

It may assist to reflect to the closest CPT (e.g., 22899 billed) and add comments like this example: "removed prominent spinous process-no lesion, like code 22101".

Use checklists to assist and no need to send documentation unless requested. When requested, providers can fax, mail, or utilize the electronic additional documentation Paperwork (PWK). Read more under Noridian’s Jurisdiction E or F:

Q10. Is it acceptable when chemotherapy begins in three days, following the first appointment, to bill a second appointment to Medicare for chemotherapy education (no other chief complaint) provided by a Registered Nurse (RN), Physician Assistant (PA) or Nurse Practitioner (NP)? Does it make a difference between oral medication and IV medication?
A10. As noted in Answer 4 and 17, there is not a billable CPT or HCPCS code, as Medicare does not pay separately for chemotherapy education. If performed during the same visit as a chemotherapy infusion, the education would be bundled into the drug infusion code.

If there is a separate, medically necessary E/M service performed, chemotherapy education may be factored into the medical decision-making for the time spent on that day. It makes no difference on the type of medication (oral or IV) and would not affect this reply for chemotherapy education.

Q11. Are physicians, NPs, and PAs allowed to be reimbursed for depression screening (G0444) in the home when performed at the same time of the subsequent AWV (G0439)? Our providers are billing G0439 for homebound patients and also perform a depression screening, but it’s denied for place of service (12), as not allowed in the home.
A11. No. HCPCS G0444 can be reimbursed on the same day as subsequent AWV only when provided in primary care settings. Since home is not considered a primary care setting (Office, Outpatient Hospital, Independent Clinic, and State or Local Public Health Clinic), Noridian recommends working with your specialty societies and reaching out to your CMS regional office.

Q12. Following a surgery, we may see patients that have transferred to ICU, with frequent neuro checks, etc., but that doesn’t necessarily warrant critical care or transfer of care. Can other specialties bill for other services when the surgeon is not performing the follow-up care?
A12. If the patient is stable after surgery, even in ICU, it is not considered critical care. Critical care services related to the surgery are included in the reimbursement when performed during the global period. If the critical care or other care is unrelated to the surgery, append modifiers 24 (unrelated E/M by the same physician or other qualified health care professional during a post-operative period) and FT (E/M visit furnished within the global period, unrelated, or when one or more additional E/M visits furnished on the same day are unrelated).

If the surgeon is not performing the post-op portion of the global period, it will be necessary to have a transfer of care in the documentation and bill with correct modifiers. The surgeon would submit the surgery with modifier 54 and the provider performing the post-op care would submit the same surgery code with modifier 55. The number of post-op days the provider is responsible for would be indicated in the Box 19 comments section of the claim. See IOM 100-04, Chapter 12, Section

When the specialist is not in the same group and they’re managing the patient’s condition, non-related to the surgery; bill appropriately and no modifiers are needed for that specialist (e.g., neurologist and endocrinologist).

Q13. Can extensive neuroplasty (CPTs 64708-64727) be reported separately from a soft tissue tumor excision (e.g., CPT 27632), or is that considered a standard surgical procedure and not separately reported?
A13. Yes, a neuroplasty is a separate procedure. Soft tissue tumor excision does not entail revision, moving or restoring a nerve in the area. However, removal of a benign tumor would not be expected to injure a named nerve in the area; so, if the nerve had to be restored or moved, it should be coded as a complication.

Q14. If a new problem is also addressed during a follow up visit, can the nurse practitioner (NP) speak with the physician to get an updated plan of care or does the physician have to see the patient in order to bill as incident to?
A14. CMS Internet Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.2, states there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment, of which the service being performed by a non-physician practitioner or (NPP) is an incidental part.

There must be subsequent services by the physician of a frequency that reflects the physician's continuing active participation in the management of the course of treatment. New problems would not be part of the provider’s established plan of care.

Verbal Q/A:

Q15. Do providers have to perform history and physical, or just one for E/M billing?
A15. Yes.CMS states for all E/M visits; history and physical exam must be performed in accordance with the code descriptors, but history and exam no longer impact visit level selection. Medical Decision Making (MDM) or time would determine the level of E/M service that is submitted. See IOM Publication 100-04, Chapter 12, Section 30.6.1.B.

Q16. Do providers have to follow 2023 E/M billing guidelines? Is it appropriate to use a table of risk from the E/M 1995 or 1997 when billing for 2023 services?
A16. Yes. Providers must follow the current 2023 guidelines when billing 2023 E/Ms.

Q17. If the only service provided was chemotherapy education, can providers bill an E/M?
A17. No. To bill an E/M, there service must be medically necessary and meet all coding criteria. As noted in both Answers 4 and 10, please see additional information.

Q18. Is there an 8-hour rule regarding for billing with chemotherapy and administration?
A18. No. Noridian is unaware of any rule except in observation. Stay tuned for an upcoming Observation webinar on December 12, 2023.

Q19. What can we do when another provider is billing services they didn’t render, resulting in duplicate denials?
A19. Medicare pays the first incoming claim. Medicare would only recoup the paid provider’s claim if there was clear evidence it was billed wrong. The providers should work together to determine how the services need to be billed. If one of them disagrees with how the claims process, they may appeal. If there is an error in billing, and the provider refuses to correct it, the provider may report possible abusive billing by following the process on either Noridian’s JE B Fraud and Abuse or JF B Fraud and Abuse page.


Last Updated Nov 20 , 2023