Medicare no longer recognizes consultation codes (99241-99245 and 99251-99255). Physicians shall code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. Please refer to the Medicare Learning Network (MLN) Matters Article, MM6740 for details.
For additional guidance, consider taking one of our E/M web-based training courses or join us for one of our informative E/M webinars (JH)(JL).
1. If we are using the 1997 evaluation and management guidelines for the examination component, do we have to use the 1995 guidelines for the history and medical decision-making components?
The history and medical decision making from the 1995 guidelines are used with both the 1995 and the 1997 guidelines. The 1997 guidelines provide the specialty examination guidelines only. The 1997 guidelines enhanced the history component by adding a status of chronic conditions.
2. How is medical necessity considered when scoring medical records?
All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, "…no payment may be made for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member." Therefore, medical necessity is the first consideration in reviewing all services.
3. Where can I find E/M specialty score sheets on the Internet?
You can find the E/M specialty score sheets on the Evaluation & Management dropdown tab on the left navigation of our website.
4. Is it acceptable to use abbreviations in the patient’s medical record?
Abbreviations may be used in the patient's medical record. If your patients' medical records contain abbreviations not commonly used, and you receive a request for medical records, please provide a key to the abbreviations. Submit the key with the medical records to assist us in the review.
1. If a physician sees a patient in the office in the morning for a new condition and again in the afternoon because the condition has worsened, should modifier -25 be appended the afternoon visit?
No. The physician would be expected to combine the documentation and bill only one E/M. Modifier -25 is used to identify a significantly, separately identifiable E/M service performed by a physician on the same date as a procedure or other service.
2. In rare circumstances, would a physician bill a second E/M service on the same date of service for the same patient?
If a second E/M service is required on the same date of service, the documentation should clearly provide evidence of the second E/M service occurring, the reason for the additional E/M service, and documentation of the medical necessity of the second E/M service. When reporting a second E/M service on the same date, the service will initially deny as only one E/M is reimbursable per day, per patient, per physician or same group, same specialty You may appeal the denial with documentation. Novitas Solutions would not expect to see two E/M services reported on the same date on a routine basis. Information on the appeals process is available in the Part B Appeals Reference Guide
3. How does Novitas review an E/M billed with modifier -25?
Modifier -25 is used to report significant and separately identifiable E/M services by the same physician on the same day of the procedure or other service. In the review of E/M services billed with the -25 modifier, Novitas Solutions will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. We also consider the additional documentation for the additional service separate from the documentation specific to the initial procedure or service to determine:
If there is a significant, separately identifiable E/M service that was rendered and documented, and
If the required components of the E/M service are supported as "reasonable and necessary" per Social Security Act, Section 1862(a)(1)(A), and
If the level of care is supported by the documentation contained in the medical records.
4. Can two physicians in the same group practice, who see the same patient on the same day, each bill for an E/M service and receive payment?
Physicians in the same group practice but who are in different specialties may bill and be paid separately without regard to their membership in the same group.
Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
How is the AI modifier used?
The principal physician of record appends modifier “-AI” to their initial hospital care visit code. This modifier identifies the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient bill without the "-AI" to indicate specialty care.
This modifier is informational only. It does not affect reimbursement. Claims which include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.
5. Can we append modifier 25 to 99211?
No, it is not appropriate to append modifier 25 to 99211. According to CMS, it is appropriate to append modifier -25 when the modifier indicates that a separately identifiable E/M service was performed that meets a higher complexity level of care than a service represented by 99211.
6. If a physician moves from one group practice to another, can the physician bill the patients as new if they go to the new practice?
The provider would not be able to bill previously seen patients as a new patient unless he meets the three year guideline for a new patient visit.
A new patient is defined as a patient who has not received any professional services, i.e., E/M services or other face-to-face services from the physician or physician group practice within the previous three years.
7. Is it acceptable to score a 99215 if the medical decision making is low?
The level of established patient visits is scored by using the highest 2 key components. However, the medical decision making (MDM) drives the amount of work conducted during the encounter. A low MDM may not support the necessity of a comprehensive history and a comprehensive exam.
For example, the medical appropriateness of a comprehensive history and comprehensive exam could be questioned for an established patient encounter if the patient is prescribed an over the counter medication such as Tylenol.
8. In E/M, if the provider does not do an exam on the patient, how do we code?
Depending on the category of E/M, the level of service would be based on the components documented. If time is an element documented and the physician documents more than half of the time was spent counseling and/or coordinating care, the level of service would be based on time.
9. How can I score a detailed exam using the interactive score tool?
The interactive score sheet will allow you to score a detailed exam only if using the 4x4 method
. You must check off the box “Score using 4x4 method”. See the image below.
When reviewing a medical record and scoring the exam, our medical staff will automatically score a detailed exam if 4 or more exam items are noted in the medical record for 4 or more body areas or organ systems. However, less than such can still be a detailed exam based on the reviewer's clinical judgment, which is considered clinical inference.
Our nurse reviewers also use their clinical knowledge while reviewing medical record documentation to determine the correct and appropriate level of care. It provides for an individual consideration, and makes the review of all services (including E/M examinations) fairer to the physician.
Clinical inference overrides the 4x4 method; and is consistent with CMS instructions for reviewing all medical records.
10. Using the 4x4 method, would 16 items between the documented organ systems meet the requirement? For instance, can a detailed exam be given if constitutional has 4 elements, cardiovascular has only 2 elements documented, respiratory has 6 elements, and GI has 4 elements.
When reviewing a medical record and scoring the exam, the interactive score sheet will automatically score only a detailed exam if 4 or more exam items are noted in the medical record for 4 or more body areas or organ systems. However, less than such can still be a detailed exam based on the reviewer's clinical judgment, which is considered clinical inference. For more information, review the 4x4 method
1. What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019?
Per CMS, the CY 2019 PFS final rule expanded current policy for office/outpatient E/M visits starting January 1, 2019, to provide that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that she or she has done so. This is an optional approach for the billing practitioner, and applies to the CC and any other part of the history (history of present illness (HPI), past family social history (PFSH), or review of systems (ROS) for new and established office/outpatient E/M visits.
To clarify terminology, we are using the term “history” broadly in the same way that the 1995 and 1997 E/M documentation guidelines use this term in describing the CC, ROS and PFSH as “components of history that can be listed separately or included in the description of HPI.” This policy does not address who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.
2. What is "status of chronic conditions"?
The 1997 Guidelines
enhanced the HPI section of the 1995 score sheet to include the patient's chronic conditions the practitioner is following or in which an exacerbation may have occurred resulting in the chief complaint and the reason for the patient encounter. The documentation in the patient's medical record must clearly state a status of the chronic condition in order to meet the requirement under the HPI status of 1, 2, or 3 chronic conditions on the 1995 score sheet. An example could be hypertension - stable on Atenolol.
3. If the physician states same/unchanged from last visit, will he receive credit for reviewing the last visit information?
Yes, only if the physician includes the documentation from the previous visit. Otherwise, the reviewer would not know what the same was or unchanged from the previous visit.
4. For the review of systems (ROS), can the physician reference a sheet that he has in the patient's chart where the physician checked off items?
Yes. However, the physician must include the sheet with all documentation for that date of service if he/she receives a request for medical records. Otherwise, the physician will not receive credit for the information on the check-off sheet.
5. Our office requests our patients complete a form regarding medication use, medical history, family history, and social history information. Can this information be included as documentation of the PFSH and ROS?
Yes, you may use this information. In order for the physician to receive credit for the information, the form must be included in the patient's record for the encounter is medical documentation is requested. It is also appropriate for the physician to note in the medical records any additional information obtained during the face-to-face encounter.
6. Can the patient's past medical history be used in scoring the ROS or HPI elements?
No. The ROS and HPI elements pertain to the chief complaint and the reason for the patient's visit that day, not past medical history information.
7. When scoring the ROS, can the systems addressed in the HPI elements be used or is that "double dipping"?
ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit.
8. Under limited circumstances, could we use “noncontributory” as appropriate documentation to support the ROS and family history sections of the history component of an E/M?
There may be circumstances where the term "noncontributory" may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E/M documentation guidelines, it is noted that, "those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented." The use of the term "noncontributory" may be permissible documentation when referring to the remaining negative review of systems.
The term "noncontributory" may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem.
9. How can we determine the difference between modifying factors and associated signs and symptoms?
A modifying factor is something done to help or alleviate the problem (i.e., "took two nitroglycerin tabs with no relief").
Associated signs and symptoms are signs and symptoms that are associated or related to the presenting problem (i.e., shortness of breath and nausea).
10. When a physician performs an E/M service and the patient is not able to provide history, if the physician documents “patient in a coma,” “patient not able to respond,” “patient unresponsive,” can they count a comprehensive history?
When a physician performs an E/M service and is unable to obtain parts of the history component for that encounter, documentation should clearly reflect the components that were not obtained (HPI, ROS and/or PFSH). Documentation should also include why the components were not obtained (patient unresponsive, sedate on a vent, etc.), and attempts to obtain information from other sources; such as a family member, spouse, nurse, etc. When the clinical reviewers are reviewing documentation, it is reviewed in its entirety. If the documentation clearly supports that the patient is not able to provide the information necessary (history components) and attempts were made to obtain the history from other sources, a comprehensive history level may be credited.
1. Under the examination section of the 1995 score sheet, can we combine the body areas and organ systems?
No. The examination section of the 1995 score sheet is divided into body areas and organ systems. The CPT manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record, you can use either the body areas or the organ systems. There is a dotted line between the body areas and organ systems indicating you must choose one or the other. If you combined the body areas and organ systems, you would be giving credit twice, which would be incorrect when determining the final score for the examination section of the score sheet. An example could be the documentation in the patient's medical record stated abdomen soft, credit can only be given in the body areas under abdomen or in the organ systems under gastrointestinal, which ever area benefited the physician the most with scoring.
2. Do body areas of the examination section of the 1995 score sheet work exactly as the organ systems?
You may count up to 7 body areas or 7 organ systems for an expanded problem focused or detailed examination and you may count 8 body areas or 8 organ systems for a comprehensive examination. However, you may not add body areas and organ systems together to determine the level of the examination.
1. How do we get credit for a test under the amount and/or complexity of data reviewed section of the E/M score sheet?
You can get credit in this section when the test (clinical lab test, test in the radiology section of CPT, or test in the medicine section of CPT) is documented as reviewed and/or ordered, and the service is medically indicated. The maximum number of tests credited in each section is one.
2. What constitutes additional workup in the amount and complexity of data grid for medical decision making?
The number of possible diagnoses and/or the number of management options considered is on the number of types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions made by the physician. For each encounter, you should document an assessment clinical impression or diagnosis. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
Additional workup in all settings is work done beyond the encounter when the physician needs to obtain more information for his medical decision-making and the results will be received when the patient is no longer present.
For example, additional work up would be if a physician sees a patient in his office, writes an order for lab tests and the results will be received requiring further evaluation when the patient is no longer present.
3. If I personally review a film, e.g. x-ray, electrocardiogram in my office, will I receive 2 points on the E/M score sheet?
Two points may be given in amount and/or complexity of data reviewed when a practitioner independently visualizes an image, tracing or specimen previously or subsequently interpreted by another physician. The medical record documentation must clearly indicate that the physician/qualified NPP personally (independently) visualized and performed the interpretation of the image, tracing or specimen. Credit will not be given if the documentation reveals the practitioner only read/reviewed a report from another physician/qualified NPP.
If the same practitioner performing the E/M service is also billing separately for the professional component of a test in the radiology and/or medicine section of the CPT, two points should not be credited for independent visualization of the same image, tracing or specimen.
In addition, the practitioner cannot take credit for review and/or order and independent visualization of the same test during the same encounter.
4. When can prescription drug management be credited in the medical decision making risk of complications chart?
Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.
If medications are just listed in patient’s medical record, credit is given for past history.
5. What do the terms 'new' or 'established' problem to the physician mean?
The terms 'new' or 'established' problem to the examiner, which appear on the score sheet, refers to whether the patient's problem or chief complaint is new to the physician or established to the physician. Is this the first time the physician is seeing the patient for this problem, or is the physician currently treating or previously treated the patient for this problem?
6. Can a provider who bills 93000 also use his interpretation in the medical decision making section when selecting a level of E/M service; for instance, when the ECG is abnormal?
If the provider performs and bills 93000 (professional and technical component), he cannot take credit for it in the E/M as the ECG includes a MDM component.
1. My patient visits are primarily counseling and coordination of care. How do I bill for this type of patient visit?
When counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during an E/M service then time may be considered as the controlling factor to qualify the E/M service for a particular level of care. If the physician elects to report the level of care based on counseling and/or coordination of care, then a number of factors must be in the patient's medical record. The following must be in the patient's medical record in order to report an E/M service based on time:
The total length of time of the E/M visit;
Evidence that more than half of the total length of time of the E/M visit was spent in counseling and coordinating of care; and
The content of the counseling and coordination of care provided during the E/M visit.
1. What is the difference between "new" and "established" patient and "new" and "established" problem? Does it mean the same for a non-physician practitioner (NPP)?
The terms "new" or "established" problem on the E/M score sheet refer to whether or not the problem is new or established to the examiner, e.g. physician/non-physician practitioner (NPP), and whether or not that problem is stable/worsening or whether the physician plans to conduct additional workup on that problem or not.
In CPT, a "new" patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the same specialty and subspecialty who belongs to the same group practice, within the past three years.
An "established" patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the same specialty and subspecialty who belongs to the same group practice, within the past three years.
CMS interprets the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.
Currently, under the CMS enrollment process, NPPs cannot designate a sub-specialty. An NPP can only designate their primary licensure, e.g. nurse practitioner, physician assistant, certified nurse midwife, etc.
2. We are seeing denials for our physician’s new patient visits indicating the patient was seen by our group in the last three years. Why is this occurring? What can we do about it?
In multispecialty groups, when an NPP sees the patient this may cause your new patient visit to deny for a physician. If you can provide documentation that shows the NPP and physician are trained in different specialties, request a redetermination of the claim with the documentation.
A new patient is a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.
Currently, under the CMS enrollment process, NPPs cannot designate a sub-specialty. An NPP can only designate their primary licensure, e.g. nurse practitioner, physician assistant, certified nurse midwife, etc.
3. I've seen a patient in my current office within the last three years. I opened a new office in a nearby state. Will the first time I see that patient in my new office constitute a new patient visit?
No, the new patient rules apply to the new location as your National Provider Identifier follows you wherever you go. A new patient is a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.
4. The March 2013 CPT assistant professional edition (page 8) states that providers may bill an office/outpatient E/M visit (99211-99215) for meeting with a patient’s family to discuss the patient’s care, without the patient present. Is this appropriate billing under the Medicare program?
No, billing office/outpatient E/M services (99211-99215), in the absence of the patient, is not billable under the Medicare program. Medicare requires a face-to0face with the patient to occur.
5. Can we bill a medically necessary visit on the same day as a preventive medicine service?
When a physician furnishes a routine physical exam as well as a medically indicated or covered visit during the same encounter, the covered visit is viewed as being provided in lieu of a part of the routine physical. For additional billing information on preventive physical exams and other preventive services, please refer to the preventive services
document located in the Claims Center of our website.
6. Can E/M visits be billed on the same day as inpatient dialysis?
Payment for E/M procedure codes 99231-99233 will be bundled into payment for inpatient dialysis procedures 90935-90947 for services rendered on or after January 1, 1995. No payment will be made for the E/M visits if billed the same day as inpatient dialysis.
1. Does Medicare allow payment for E/M visits in a patient's home?
Home services CPT codes 99341 through 99350 are used to report E/M services furnished to a patient residing in his or her own private residence (e.g., private home, apartment, town home) and not residing in any type of congregate/shared facility living arrangement including assisted living facilities and group homes. The home services codes apply only to the specific 2-digit POS 12 (home). Home services codes may not be used for billing E/M services provided in settings other than the private residence of an individual as described above.
2. Can a podiatrist bill a home visit?
Yes, as long as home visits are within the scope of practice and state licensure for podiatrists, and the service rendered is medically necessary.
1. When a patient presents to an emergency department prior to midnight and the physician sees them after midnight, which date of service do we report?
The date of service would be the date the physician performs a face-to-face service with the patient.
1995 Documentation Guidelines for Evaluation and Management Services