ACT B Questions and Answers - April 20, 2022

The following questions and answers (Q&As) are cumulative from the general Part B Ask the Contractor Teleconference (ACT). Some questions have been edited for clarity and answers may have been expanded to provide further details. Related questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed this directly with the provider. This session included pre-submitted questions and verbal questions posed during the event.


Q1. Can Noridian provide instructions on the COVID-19 administration HCPCS 0011A that had a mass adjustment, and we still do not have resolution for approximately 30 claims?
A1. Yes, there was a mass adjustment in May of 2021 and if the provider has any more claims with this HCPCS 0011A administration issue, cancel the adjustment and submit a new claim. On the line 19 narrative field, reflect "timely filing waived per Medicare fee issue".

Q2. Regarding bilateral Radiofrequency Ablation (RFA) LCD L38801 policy; if a patient has not had an RFA for two years or more, do the diagnostic procedures need to be repeated?
A2. Depends. If the provider is sure the pain is from the same level previously blocked, then s/he does not need to repeat the diagnostic blocks. The LCD, Facet Joint Interventions for Pain Management, addresses the frequency and number of services, as well as when repeat services are appropriate.

If the dual Medial Branch Blocks (MBBs) provided >80% pain relief and the initial RFA received at least 50% improvement in pain for at least six months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs, a repeat RFA can be performed. These would be at least six months from one another and in addition, each encounter date that a facet procedure is performed is one session.

Q3. What level of detail must be documented to support billing with modifier -AS (non-physician practitioner (NPP) assistant at surgery)?
A3. If the code is eligible, the provider must provide a documentation level to clearly reflect the role of the assistant, during the procedure, with the medical reason the patient required an NPP assistant at surgery. Make sure that the CPT allows assistant surgeons found under Noridian's Fee Schedule "Indicators and Descriptions."

An operative report may be requested. Noridian does have documentation guidelines on our website under Medical Review's tab.

Q4. With Acupuncture for Chronic Low Back Pain, can the physician supervise auxiliary personnel, under incident to rules of direct or general supervision, if all applicable state requirements met?
A4. Yes. The authorized Medicare billing provider must directly supervise all auxiliary personnel. The National Coverage Determination (NCD) policy allows acupuncture to be performed by auxiliary personnel, but s/he must be under the direct supervision. As required by Medicare’s Code of Federal (CFR) regulations (42 CFR §§ 410.26 and 410.27), the supervising physician must be able to oversee the treatments in the office and be actively involved with that patient's care.

Q5. What does Noridian expect to see documented in order to support independent interpretation? How does Noridian interpret the "surgery" guidelines around tests and treatments considered, but not selected?"
A5. Documentation for independent interpretation should indicate a review of the results in the provider’s own words. There should be additional work shown to support a separate interpretation other than the one received. Tests or treatments considered, but not selected, would need to be documented in the medical record. In determining surgery levels with the E/M services, the professional interpretation of those tests and studies are reported separately by the physician or other qualified health care professional.

Tests that do not require separate interpretation (e.g., test results only) are analyzed as part of Medical Decision-Making (MDM) and do not count as an independent interpretation; however, may be counted as ordered or reviewed for selecting an MDM level.

Q6.If the beneficiary is considered Homebound and receiving Home Health and is referred to an Outpatient pain rehab program, can the patient receive telehealth psychology services without jeopardizing his or her homebound status? Do we bill Medicare or Home Health?
A6. The psychologist telehealth visits would be billed to Part B and should not jeopardize their Homebound status. Since Noridian only adjudicates Part A, B, and Durable Medical Equipment (DME) claims, if Home Health does not employ the provider, append modifiers -GV (attending physician not employed or paid by patient's hospice provider) or -GW (service not related to hospice terminal condition).

Providers should refer to Home Health Consolidated Billing (CB) Master List found on CMS’ Home Health page Coding and Billing Information. This ensures their specific procedure code does not fall under home health CB.

Q7. Do Opioid Treatment Program (OTP) providers bill only with the group NPI # in Box 33 and no individual NPI # in Box 24J?
A7. Yes. Check with your electronic data interchange (EDI) partner to confirm the correct billing for OTP on the CMS-1500. Box 24J, the individual NPI#, is NOT needed as OTP is not considered physician services. Item 24J - Do not bill individual provider NPI and leave blank or bill OTP group NPI from Item 33. More information under Noridian Browse by Topics, under Drugs and Bios, OTP section.

Q8. When these two services, CPTs 93458 (coronary angiography) and 92978 (intravascular ultrasound (IVU) are performed by two different providers who bill separately; how should the +92978 add on code be billed by the provider who did not perform the left heart catheter? S/he only billed the IVU and there was no intervention based on coronary images.
A8. Again, if cardiac procedures are billed by two different providers, the second provider would not bill able to bill for the add on CPT +92978, as there must be a primary CPT (e.g., 93458) to bill add on codes. Occasionally, billing an undifferentiated code and indicating exactly what is being performed may help. Co-surgeon only works if both are from the same practice. Please check with your respective societies to resolve nationally.

Q9. Can physicians bill CPT 93355, who are not performing the structural heart procedure, and only the TEE interpretation?
A9. Looking at the Noridian Medicare Physician Fee Schedule (MPFS), you will see that CPT 93355 is a global code that cannot be split into technical and professional interpretation. As only one payment allows, if there is a separate physician reading the transesophageal echocardiogram (TEE), it will be up to the entity how to pay that other professional "reading" portion of the code.

Q10. Can a beneficiary have pulmonary rehab (PR) if COVID is the ONLY diagnosis and the beneficiary experiences persistent symptoms that include respiratory dysfunction for at least four weeks?
A10. Yes. They can participate in PR if they have COPD confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks. They would NOT need to have the COPD diagnosis, if the COVID-related issues are the problem.

Beneficiaries who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks and complete PR, may participate in PR again if they have moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease.

Q11. Will there be any future reform or changes to the required amount of intra-service time for billing Moderate Sedation services (CPT 99151-99157) with Elective Cardioversion (CPT 92960)?
A11. Any future reform or changes would be published from CMS. Watch proposed and final rules that publish through the Federal Register and CMS websites. Specialty societies are a resource to suggest changes as well.

Q12. What are acceptable examples of medically necessary E/M services in the context of prolonged services with direct patient contact?
A12. The medical necessity would be determined based on the patient's condition(s) and the status of the patient. A condition that has exacerbated and requires additional time to treat or counsel the patient, should include documentation of the status for the condition, along with the time spent.

Q13. Is there a department to obtain a specific account remit list that are offset?
A13. Offsets can be viewed in the Noridian Medicare Portal (NMP). Search under specific claim remittance, type in the provider information and the Internal Claim Number (ICN) claim number. The ICN is the financial control number (FCN) of the offset, minus the first two digits. 

To look up what beneficiary a withholding (PLB reason code=WO), the NMP provides information under "Claim Specific Remittance Advice Inquiry". Type the provider information and ICN claim number in the details. Under "Financials", enter provider information and the letter number or ICN. This also provides the debt balance as well.

Q14. For COVID-19 mass vaccination sites, do we need to complete a Medicare Secondary Payer Questionnaire (MSPQ)?
A14. CMS determined in 2021 that the MSPQ would not be mandated for COVID vaccine administrations.

Q15. When a Skilled Nursing Facility (SNF) or Hospice patient is seen by another Part B provider for an outpatient, unrelated service, can we bill Medicare Part B?
A15. When a patient is in a SNF stay, a physician's professional service could be billed. Refer to the Consolidated Billing at CMS Skilled Nursing Facility (SNF) Consolidated Billing. For Hospice patients, if the patient is seen for a condition unrelated to their Hospice stay, providers may append modifier -GV (attending physician not employed or paid by patient's hospice provider) or -GW (service not related to hospice terminal condition).

Q16. Will HCPCS C1734 (orthopedic implantable device) be reimbursed with the J7 pass-through status code that is "Contractor Priced"? Are there pricing limitations and is there a policy?
A16. C1734 always requires an invoice, and this information can be found on Noridian's Claims page, Claim Submission Billing, Errors, and Solutions, "Avoiding Denials on Priced Per Invoice Claims". It can be billed with CPTs 27870, 28715, and 28725. Currently, there is no Local Coverage Determination (LCD) or National Coverage Determination (NCD) policy attached to this code. A web page update on pass-through devices has been added.

Q17. How should we list CPTs when notes and medical necessity support units over the allowed MUE? Ex: if supported to bill 36 units of 11045, do you want 36 units on one line, or split by MUE (12) on three lines with or without modifiers -59 or -76? Since we appeal, does it matter?
A17. Yes, it does matter. If your practice is billing OVER the approved MUEs; none of them may be paid. This allows you to appeal with supporting documentation for all the "units." Billing on one line with all the units is preferred. See additional information on our Noridian claims MUE webpage under    

Q18 Please clarify the use of modifier "CS" for COVID-19 and respiratory testing (CPTs 87631-87633)?
A18. Modifier -CS (cost-sharing) waiver is not an appropriate modifier for those tests. During the COVID-19 PHE, modifier -CS for COVID-19 testing-related services, is only allowed on evaluative services outlined in the Medicare Learning Network (MLN) Article, Special Edition (SE) 20011. Clinical lab tests on the Clinical Laboratory Fee Schedule (CLFS) already pay at 100 percent of the fee schedule allowed amount.

Q19. Our lab is seeing National Correct Coding Initiative (NCCI) edit denials and need compliant information on a) ordering provider chart notes needed? b) Must a lab bill for every target that it tests? c) Must the lab bill Medicare for all the services it provided?
A19. All lab services must contain one of the following:

  • Signed order or requisition listing specific test
  • Unsigned order or requisition, with authenticated medical record listing specific test(s) and authenticated medical record with physician’s intent to order tests (e.g., "order labs", "check blood", "repeat urine")

Further documentation requirements for labs can be located in CMS’ Medicare Learning Network (MLN) booklet at Complying with Laboratory Services Documentation Requirements.

All separately reportable services must be billed to Medicare in accordance with Section 1848(g)(4) of the Social Security Act. In accordance with the Internet Only Manual (IOM) Publication 100-04, Claims Processing, Chapter 12, Section 30(A); if a provider knows a service is bundled into another procedure, then they should not be separately reporting on a claim as they would already be receiving payment for the "comprehensive code." It would be the provider’s responsibility to obtain an Advance Beneficiary Notice (ABN) or accept the denial.

Q20. Where can I find information on reconstructive eye surgery, including reporting grafts and flaps?
A20. Refer to the Local Coverage Determination (LCD) policy and its Billing and Coding Companion-Local Coverage Article (LCA) on Blepharoplasty, Eyelid Surgery and Brow Lift found on the Noridian Websites under Policies.

Q21. How can our appeals be allowed for HCPCS J1040, when we send in medical records for Medically Unlikely Edits (MUEs) over the approved amount?
A21. If your office is experiencing a large volume of MUE denials related to J codes, it is encouraged that verification of the correct units are being billed and appropriate dosing is administered by the provider. It is recommended that documentation submitted supports the medical reasonableness of the service(s) performed. Since MUEs associated with drugs (J codes) are typically set by the NCCI, based on the manufacturer’s prescribing recommendations or CMS-approved drug compendia.

Q22. Where would Eyeglass prescription fall under Risk of Complications and/or Morbidity or Mortality of Patient Management? Can we count this as Prescription Drug Management or Low risk of morbidity?
A22. Eye exams for prescribing, fitting, or changing eyeglasses are considered a noncovered charge per the CMS’ MLN booklet, Items & Services Not Covered Under Medicare. Eyeglass prescriptions would not meet drug management or count toward Medical Decision-Making (MDM) of a covered E/M. See the Risk definition included in the CPT 2022 book and on Noridian’s website under the Browse by Specialty, E/M section.

Q23. For an urgent care E/M visit, would a referral to a specialist count as Low or Moderate risk?
A23. A notation in the medical record indicating another practitioner is treating, without additional assessment or care coordination, does not qualify for medical decision-making (MDM). Referral without evaluation (by history, exam, or diagnostic study{ies}) or consideration of treatment, also does not qualify for MDM as nothing is being addressed or managed. To assign your category of MDM, address the problem, utilize the problem level, amount, data complexity, and risk to the patient referred.

Q24. What are Noridian’s billing guidelines when the amount of a medication (HCPCS J3111-Evenity, 210 mg) is split into two injections at 105 mg each), instead of administered as one injection on the same day? Would the CPT 96372 administration be billed on one line or two lines with the second line reflecting 96372-59?
A24. Bill 96372 on one line without modifier -59. Since the kit contains one dose of two injections, for a total of 210 mg, the administration covers both injections.  

Q25. In Podiatry, if the patient has evidence of neuropathy; however, no vascular impairment, are class finding modifiers required? If one of these diagnoses is billed, is it payable with or without a class-finding Q modifier on the claim?
A25. The Local Coverage Article (LCA) from the NCD below shows Group diagnoses codes for neuropathy do NOT require a Q modifier to be paid. The Group 3 paragraph indicated the diagnosis below do require the Q modifier.
Providers must include a systemic condition diagnosis listed from the Internet Only Manual (IOM) 100-02, Chapter 15, Section 290. All claims for routine foot care, based on the presence of a systemic condition, must have a billing modifier of Q7, Q8 or Q9 to be considered for payment.

Read more at "Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy)" under National Coverage Determination (NCD) 290.2.

Q26. CPT 93319 (new 2022) is receiving an CCI edit when trying to bill CPT add on code +93325 (doppler echocardiography) and 93319 (3D echocardiographic imaging, etc.). We requested to have 93325 removed from the "do not report" parenthetical. However, this change may not take place until 2023. Will Noridian accept our current billing of 93325 and 93319?
A26. No. CMS requires Medicare Administrative Contractors (MACs) to follow the National Correct Coding Initiative (NCCI) edits. There is a current edit in place to deny CPT 93319 when billed with 93325.

If this edit is updated with the information you have indicated, Noridian will be able to allow 93319 when billed with 93325. If you have not already submitted a request to change this edit, follow the guidance provided on this website: National Correct Coding Initiative Edits.

Q27. Can we get clarification that Osteopathic Manipulation Treatment (OMT) procedures do or do not include initial evaluation and management (E/M) and appropriate billing when performed on the same date of service?
A27. CMS requires MACs to follow the National Correct Coding Initiative (NCCI) edits. There is a current edit in place to deny Evaluation and Management (E/M) codes when billed with Osteopathic Manipulative Treatment (OMT) codes 98925-98929. This edit is indicated as following CPT manual. You may refer to guidance provided in the 2022 CPT book and when modifier -25 may be appropriate to append to the E/M code.

Q28. Another physician who is caring for the patient requests that the outside image be re-read by one of our radiologists. The Medicare Claims Processing Manual, Chapter 13, Section 100.1 states that "Generally A/B MACs (B) must pay for only one interpretation of an EKG or X-ray procedure furnished to an emergency room patient. They pay for a second interpretation (identified through modifier "77"), only under unusual circumstances (for which documentation is provided); such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed or a changed diagnoses resulting from a second interpretation of the results of the procedure". Does this same guidance regarding unusual circumstances, application of modifier -77 and additional documentation requirements apply outside of the emergency room (ER)?
A28. Medicare pays for only one read, even in the ER, unless it is medically necessary to have an additional read.

Q29. Does critical care state that the entire 30 minutes (over 74 minutes) must be spent to bill CPT 99292 by a single practitioner? What about in the same specialty, subsequent providers? When documentation shows 80 minutes of critical care, can the additional critical care (CPT 99292) be added to CPT 99291? Is it after 75 minutes spanning to 104 minutes?
A29. Yes. CMS allows providers, in the same specialty, to report concurrent follow-up care for subsequent critical care time intervals. IOM 100-04, Chapter 12, Section follows the table on our website. "Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported, by a practitioner in the same specialty and group, when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes)."

To reiterate, first, there must be at least 30 minutes documented to be able to bill add-on code 99292. If we add 30 minutes to 74 minutes, 99292 can be reported at 104 minutes (not at 75 minutes). The follow up care that does not meet the critical care criteria does not get added.

For example, subsequent care Internist A = initial critical care, 70 min 99291 x 1. CPT 99291 would still be reported by one provider in same specialty, per DOS. Internist B = subsequent critical care later in the day, 90 minutes 99292 x 3.

Q30. Does a single practitioner have to provide 104 minutes of critical care, BEFORE they can bill 99291 and one unit of 99292?
A30. No. See Q/A #29 above. At least 74 minutes + 30 minutes = 104 total minutes, as the duration is between 75-104 minutes. Billing would read 99291 x 1 and 99292 x 1. The CMS Internet Only Manual (IOM) 100-04, Chapter 12, Sections and, states 99292 for additional 30-minute time increments provided to the same patient.

For example, if Pulmonologist A = 20 mins. of critical care (unbillable as did not reach minimum time). Pulmonologist B = 30 mins. of critical care now qualifies with 50 total minutes, so one claim is billed with aggregated time for 99291. There is no 99292 added in this scenario.


Q31. How do we get reimbursed when place of service (POS) 65 is denied for billing Transitional Care Management (TCM) CPT 99496 in the dialysis unit for End-Stage Renal Disease (ESRD) and Cardiokymography(CKG)?
A31.  Place of service 65 is allowed for TCM when billed with 90960-90962 or 90970 on the same claim. The example provided appears to have denied because add on CPT 99496 was billed on its own in POS 65. It cannot be billed on its own if rendered in POS 65. The additional 909xx code would provide the information that your facility is treating this patient for the month. When the patient is part of the Kidney Innovation Model, the claim will process correctly with zero payment.

Q32. Claims are denied for the Home Sleep Study (HST) HCPCS G codes, with POS 11 and allowing POS 12. The home sleep study is done in the office setting up the patient, onsite visit in the office. Our doctor instructs the patient at the office how to use, then the patient takes the equipment home and returns the next day.
A32. POS 12 is correct when billing the HST with G0398 – G0400. This includes set up, take down, interpretation and report.

Q33. J7170 is one of the only medications covered by Medicare Part B and not DME. Patients would self-administer in the home just like hemophilia clotting factor. Does J7170 (Hemlibra-emicizumab-kxwh) fall under the home administration benefit and could a pharmacy bill?
A33. Noridian does have a Billing and Coding article entitled "Billing Limitations for Pharmacies" (A56124-Jurisdiction F). At this time, in the article it does allow Medicare Part B payment for J7170 when billed with Pharmacy (specialty A5). Please see the article for exact verbiage and guidance. Noridian had a glitch in the system that was preventing this from happening and is now rectified.

Q34. We have patients that have more than twelve diagnoses and our electronic medical records (EMR) only sends twelve at a time. We are part of a demonstration project for advanced illness process. Can you use this to send the additional diagnosis for a second claim unspecified E/M (CPT 99499) just to report the additional diagnosis?
A34. No. An additional code should not be billed just to report additional diagnosis. Only reflect the significant twelve "acting" codes. Medicare understands that patients may have several chronic conditions. The claim and paperwork for a demonstration may differ for that purpose.

Q35. We often treat patients with acute injuries or illnesses with ibuprofen 800 mg, etc. For the E/M MDM, does over the counter (OTC) at prescription drug strength qualifies for the risk?
A35. We do know high doses are provided and have impacts (i.e., kidney). The level of risk depends on the polypharmacy. There can be, depending on the situation, risk from OTC medications and can be included as one of the many factors involved in decision making.

Q36. Is CPT 99406 covered with diagnosis Z7891? Are you really counseling them to quit smoking?
A36. Please see Noridian’s website under Preventive Services, Counseling to Prevent Tobacco Use for a list of diagnoses. Z87.891 (personal history of nicotine dependence), not Z7891 is listed. 99406 and 99407 replaced HCPCS G0436 and G0437 for symptomatic individuals. Patients must be using tobacco, competent and alert at time of counseling and furnished by qualified physician or another Medicare-recognized practitioner. See also the National Coverage Determination (NCD) at CMS NCD 210.4.1 Counseling to Prevent Tobacco Use.

Q37. Can the Medical Decision-Making (MDM) for prescription drug management in the electronic medical record (EMR) to show the success or change in strength and dosage?
A37. Place in the EMR where it cannot be misunderstood to prevent duplication. The more places you can list for safety of the patient, the better. It’s a matter of quality of assurance for as many people taking responsibility for the patient have access to this information. The record needs to evidence what service was performed.

Q38. When billing an unlisted procedure, because there is no allowed CPT, how does Noridian make the decision if the service will be covered?
A38. Medicare would normally ask for additional records to support the service. Providers can fax, mail, or utilize the electronic additional documentation Paperwork (PWK). Read more at

Q39. When determining shared visits (new or established) and documenting time, is the mid-level advanced practice provider (APP) and MD required to document their total time or can the MD reflect they performed substantive time without documenting minutes? Since split and shared services are inpatient, how will Noridian look at this if their specific time in minutes is not documented. If they are billing based on time, and the MD said "performed substantive portion of time" but didn’t have minutes spent, would Noridian accept this?
A39.  No. Inpatient split and shared visits would not follow the newer 2021 E/M guidelines, as that allows total time to be billed only for office-based services (99202-99215). Do not reflect "not reported."  If time is not listed, providers need to default to the other elements. As of January 2022, Modifier FS should be appended. A split/shared visit must be billed under the NPI of the individual who performed the substantive portion of the visit. For calendar year 2022, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit. That individual must sign and date the medical record. Watch for possible updates in 2023 and read more under the Internet Only Manual (IOM) titled Split (or Shared) Visits, effective 2-15-22at CMS IOM 100-04, Chapter 12, Section 30.6.18 that state "Beginning January 1, 2023, substantive portion means more than half of the total time spent by the physician and NPP performing the split (or shared) visit."

Q40. We have several denials for 0296T, 93242 or 93246 depending on length of the recording. Physicians bill 93000 (EKG) and then determining if the patient needs the placement. Medicare is not allowing per the NCCI edits.
A40. CPT 93000 bundles with 9324X codes. Modifier -59 can be added to unbundle IF they do not relate and are independent services. Also, check to see if the EKG should have only been billed as technical (93005) or professional (93010). See also Q/A #41 below.

Q41. Can Noridian provide guidance on billing 93242 (cardiovascular ECG monitoring-more than 48 hours-up to 7 days) or 93246 (cardiovascular ECG monitoring-more than 7 days-up to 15 days) with 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report)? Since moving from temporary 0296T status, our office is having a difficult time getting the ZIO XT heart monitor placement with a separate EKG, paid on the same DOS.
A41. See also Q/A #40 above. You may want to look at CPT 93241 instead. Per NCCI, 93242 and 93246 can never be billed together, because of a "zero" indicator. However, 93000 can be unbundled with modifier -59, when billed with either 93242 or 93246. Also, take a look at the National Coverage Determination: NCD 20.15 Electrocardiographic Services and under Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring.

Q42. We have issues with unlisted codes rejecting through our clearinghouse. How do we get unlisted code claims through for (e.g., 77399) with a modifier -26?
A42. Do not append modifiers to unlisted codes. That is the reason it is rejecting. Explain in the narrative field (Item 19) that this is for the professional only (-26) and in the documentation.

Q43. For Medicare acupuncture supervision of the chronic low back pain, does the physician need to be in the same building, as opposed to somewhere on the campus with more than one building? What is required for supervision vs. remote supervision (with real time audio-video) allowed for a short term due to public health emergency (PHE)? There could be other physicians who are not supervising in the same building.
A43. Direct supervision means the supervising physician must be in the same building; in fact, usually on the same floor, to be "immediately available to assist." Remote supervision does not meet this requirement. Here’s the link at NCD 30.3 Acupuncture. All indications for acupuncture outside of NCD section 30.3.3 remain non-covered. Medicare patients must receive acupuncture from a doctor, or by another health care provider (like a nurse practitioner or physician assistant) who must have both:

  • Masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine
  • Current, full, active, and unrestricted license to practice acupuncture in state where providing care

Reminder as specified in the interim final rule (IFC-85 FR 19245-19246), during the PHE when physicians and other health care professionals are faced with challenges regarding potential exposure risks for themselves and their patients, the direct supervision requirement that applies for most other services that are furnished incident to a physician or other practitioner’s services may be met virtually through audio/video real-time communications technology.

Q44. Physicians will perform deep sedation (especially with pediatric patients), instead of moderate sedation. CCI edits bundle when the same physician is performing medical treatment and sedation (e.g., fracture reduction or shoulder dislocation-CPT 23655) and cannot bill moderate. Medicare does not allow separate payment for anesthesia except with limited exceptions. The doctor is performing a riskier sedation at a reduced reimbursement. How can we receive additional reimbursement?
A44. This should not be performed by the physician and would be denied in appeal. It would not be expected that a physician reducing the shoulder would be conducting the deep or general anesthesia. Depending on the patient status, the provider may have to prove that situation through an appeal. These types are set up as general anesthesia which is considered deep sedation.


Last Updated Nov 13 , 2023