Evaluation and management FAQs

1. Where can the CPT E/M code and guideline changes for 2021 be found?

The CPT E/M code and guideline changes for 2021 can be found in the American Medical Association (AMA) CPT® E/M office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99XXX) code and guideline changes for 2021.

2. Where can the revised medical decision-making table for 2021 be found?

The revised medical decision-making table can be found in the AMA Table 2 - CPT® E/M office revisions level of medical decision making (MDM).

3. There are 22 new definitions in the CPT E/M changes for 2021. Where can the 22 new definitions be found?

The new definitions can be found in the AMA CPT® E/M code and guideline changes for 2021.

4. Can we still bill 99201-99205 and 99211-99215 based on the 1995 and 1997 guidelines for dates of service on and after January 1, 2021?

Office/outpatient visits prior to January 1, 2021 may still be billed using the 1995 or 1997 guidelines. Providers must bill office/outpatient visits provided on or after January 1, 2021 using the CPT E/M code and guideline changes for 2021.

Note: Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, 2021.

5. Do the 2021 E/M code and guideline changes apply to all categories of E/M services?

No. The E/M code and guideline changes are specific for office and other outpatient visits and apply to codes 99201–99205 and 99211–99215.

Note: Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, 2021.

6. For dates of service on and after January 1, 2021, how are the levels of E/M services provided in an office/outpatient setting determined?

Effective for dates of service on and after January 1, 2021, you would select the appropriate level of E/M service based on the following:

7. Does the revised medical decision-making table for 2021 provided by the AMA apply to all E/M services?

No. The CPT E/M code and guideline changes for 2021 and subsequent MDM table only apply to office/outpatient E/M services beginning January 1, 2021. All other E/M categories and codes continue to follow the 1995 and/or 1997 E/M guidelines.

8. Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines?

The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines.

While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.

The revised code descriptors state a "medically appropriate history and/or examination" is required.

9. Is time defined differently for office and outpatient E/M services effective for dates of service on and after January 1, 2021?

For dates of service on and after January 1, 2021, time is defined as minimum time, not typical time, and represents the total physician or other qualified health care professional time on the date of service. The use of 'date-of-service time' builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services, like care coordination.

This definition applies only when code selection is based on time and not MDM. 

10. When coding by time, is the day of encounter by calendar date or 24-hour period?

When coding by time, only the time spent on the actual date of the encounter is applicable.

11. How is time counted under the CPT E/M code and guideline changes for 2021?

Except for code 99211, per AMA, beginning with CPT changes 2021, time alone may be used to select the appropriate code level for the office or other outpatient E/M service codes (99202-99205, 99212- 99215).

Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.

When time is used to select the appropriate level for E/M service codes, time is defined by the service descriptors. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health professional.

For office or other outpatient services, if the physician’s or other qualified health professional's time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use code 99211.

12. What activities are included in physician's time?

Physician/other qualified health care professional time includes the following activities when performed:

13. Does Novitas have a score sheet based on the CPT E/M guideline changes for 2021?

Effective for dates of service on and after January 1, practitioners will have the choice to document office/outpatient E/M visits via MDM or time. CMS is adopting the AMA's revised CPT guidance, including deletion of CPT code 99201. The E/M code and guideline changes are specific for office and other outpatient visits and apply to codes 99201–99205 and 99211–99215. Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, as clinicians may choose the E/M visit level based on either medical decision making or time; both CPT code 99201 and 99202 require straightforward medical decision making, therefore the decision was made to delete CPT code 99201.

To assist providers with this change, the E/M interactive score sheet (JH)(JL) has been updated. The updated score sheet will function based on the date of service and type of visit. If the date of service is on and after January 1, and related to an office or outpatient services visit, the score sheet options will align with the AMA guidance to determine the level of E/M service performed. If not related to office or outpatient services, or the date of service is prior to January 1, the score sheet options will remain based on the 1995 guidelines. Helpful resources and tips will be available within the tool as an added resource to guide providers in determining the level of E/M service.

14. How do other requirements (e.g., teaching physician, incident to, new vs. established) apply when using the CPT E/M guidelines for 2021?

CMS is adopting the AMA's guidance on coding office/outpatient E/M visits. Most rules remain unchanged.

15. Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?

Per AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.

For more information, please review the AMA CPT® E/M code and guideline changes for 2021.

16. When auditing MDM, is there a list of drugs considered “drug therapy requiring intensive monitoring for toxicity?”

CMS itself has not provided such a list for use with the 1995 or 1997 guidelines. This question is answered in the CPT changes for 2021:

“Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.”

For more information, please review the AMA CPT® E/M code and guideline changes for 2021.

For additional guidance, please review our article on critical care services.

1. Can certified registered nurse practitioners (CRNPs) and physicians report critical care as split/shared?

No. Per CMS, a split/shared E/M service performed by a physician and a qualified non-physician practitioner (NPP) of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.

2. Can a CRNP bill for critical care under his/her own provider number?

Critical care services may be provided by qualified NPPs and reported for payment under the NPP’s NPI when the services meet the definition and requirements of critical care services in Sections A and B. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s). Collaboration, physician supervision and billing requirements must also be met. A physician assistant shall meet the general physician supervision requirements.

CMS IOM Publication 100-4, Claims Processing Manual, Chapter 12, Sections 30.6.12 & 30.6.13

3. Can critical care services be split/shared or split between a physician and NPP?

No. You cannot report a split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) as a critical care service. The critical care service reported should reflect the evaluation, treatment and management of the patient by the individual physician or qualified non-physician practitioner and not represent a split/shared combined service.

4. Can a physician and a NPP from the same group practice both be paid for providing critical services on the same day?

Yes, however, the initial critical care time must be met by a single physician or a qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date. A history or physical examination performed by one group partner for another group partner in order for the second group partner to make a medical decision would not represent critical care services.

If the physician is performing the initial critical care service and the NPP is providing additional minutes, the physician bills with 99291 and the NPP bills with 99292. There are times were the NPP may see the patient first and perform critical care services. In this scenario, the NPP will bill the 99291 and the physician would bill the 99292.

5. Can multiple physicians bill 99291 on the same day to the same day?

Yes, physicians of different groups with different specialties and physicians in the same group practice with different specialties may bill and be paid. For example, if a cardiologist and an endocrinologist are group partners and the critical care services of each are medically necessary and not duplicative, the critical care services may be reported by each regardless of their group practice relationship.

Two or more physicians in the same group practice who have different specialties and who provide critical care to a critically ill or critically injured patient may not in all cases each report the initial critical care code (99291) on the same date. When the group physicians are providing care that is unique to his/her individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies) then the initial critical care service may be payable to each.

However, if a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the “covering” physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292. The appropriate individual NPI number shall be reported on the claim. The services will be paid at the specific physician fee schedule rate for the individual clinician (physician or qualified NPP) billing the service.

6. Is time required to be documented for critical care services and if so, how should it be documented?

Yes, critical care is a time-based service and documentation must include the total time the critical care services were provided for each date and encounter entry. The physicians can document total time and/or start and stop times.

7. If the physician performs 30 minutes or more but not the full 74 minutes for the initial critical care code, how are the additional minutes reported?

Reporting the additional minutes is determined by who is providing the service:

8. Can critical care codes be used for billing palliative services?

No, palliative care does not meet the definition of critical care services.

9. How do we count 'time' when the teaching physician is providing critical care services?

Teaching physician care must meet both the critical care and the teaching physician criteria in addition to the following:

10. Can a physician bill critical care services on the same day as an emergency department visit?

No, hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient. When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291 - 99292 may be reported. An emergency department visit code may not also be reported.

11. If care is delivered in a moment of crisis or emergently, is it considered 'critical care'?

Not necessarily; although critical care may be delivered in a moment of crisis or emergently, this is not a requirement for providing critical care service.

Critical care is defined as "the direct delivery by a physician(s) medical care for a critically ill or critically injured patient… (which) acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."

Per the CMS IOM Publication 100-04, Chapter 12, Section 30.6.12, critical care services "encompass both treatment of 'vital organ failure' and 'prevention of further life-threatening deterioration of the patient's condition.' The treatment and management of the patient's condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician's visit)."

Even if care is given in a moment of crisis, or if a provider is called to the patient's bedside based on a potential that the patient's health is in serious jeopardy, or to avoid serious impairment or dysfunction, these points alone do not meet the requirement for providing critical care: "vital organ failure" and "prevention of further life threatening deterioration" are not universally evident in these scenarios. However, care provided during a "moment of crisis" or "upon being called to the patient's bedside emergently" may result in critical care being provided if these points can be shown. For each case, documentation should indicate the medical necessity of the level/type of treatment.

Additionally, critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate evaluation and management code, such as subsequent hospital care.

CMS IOM Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.12

12. Can you clarify the circumstances when an E/M service can be billed on the same day as critical care?

When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291-99292 may be reported. An emergency department visit code should not be reported. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.

When critical care services are provided on a date where an inpatient hospital or office/outpatient E/M service was furnished earlier on the same date (at which time the patient did not require critical care), both the critical care codes and the previous E/M service codes may be billed and paid.

Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as other E/M services provided to a patient by the same physician or physicians of the same specialty in a group practice.

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:

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 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.

5. How is the AI modifier used?

6. 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.

7. 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.

8. Is it acceptable to score a 99215 if the medical decision making is low?

For dates of service prior to January 1, 2021, the level of established patient visits is scored by using the highest 2 key components. 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.

Note: Effective January 1, 2021, for office/outpatient E/M visits, the 1995 and 1997 E/M guidelines will no longer be used. Practitioners will have the choice to document office/outpatient E/M visits using medical decision making (MDM) or time. For further guidance, see the AMA CPT E/M office visit revisions and the AMA Table: CPT E/M Office Revisions - Medical Decision Making (MDM).

9. 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.

Note: Effective January 1, 2021, for office/outpatient E/M visits, the 1995 and 1997 E/M guidelines will no longer be used. Practitioners will have the choice to document office/outpatient E/M visits using medical decision making (MDM) or time. For further guidance, see the AMA CPT E/M office visit revisions and the AMA Table: CPT E/M Office Revisions - Medical Decision Making (MDM).

10. 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.

11. 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 article.

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?

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. 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"?

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 was the same 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.

Note: Effective January 1, 2021, for office/outpatient E/M visits, the 1995 and 1997 E/M guidelines will no longer be used. Practitioners will have the choice to document office/outpatient E/M visits using medical decision making (MDM) or time. For further guidance, see the AMA CPT E/M office visit revisions and the AMA Table: CPT E/M Office Revisions - Medical Decision Making (MDM).

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?

Note: Effective January 1, 2021, for office/outpatient E/M visits, the 1995 and 1997 E/M guidelines will no longer be used. Practitioners will have the choice to document office/outpatient E/M visits using medical decision making (MDM) or time. For further guidance, see the AMA CPT E/M office visit revisions and the AMA Table: CPT E/M Office Revisions - Medical Decision Making (MDM).

6. Can the patient's past medical history be used in scoring the ROS or HPI elements?

7. When scoring the ROS, can the systems addressed in the HPI elements be used or is that "double dipping"?

8. Under limited circumstances, could we use “noncontributory” as appropriate documentation to support the family history section of the history component of an E/M?

There may be circumstances where the term "noncontributory" may 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?

1. Under the examination section of the 1995 score sheet, can we combine the body areas and organ systems?

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 an 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 several 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:

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.

2. If a patient is seen in the emergency department, then admitted to the hospital, how should this be billed?

The CMS internet-only manual states A/B MACs (B) pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

1. Does Medicare allow payment for E/M visits in a patient's home?

2. Can a podiatrist bill a home visit?

1. What is required to bill based on time in the inpatient setting?

In an inpatient setting, time is defined as unit/floor time which includes time the physician spends on the patient’s hospital unit as well as time spent at the patient’s bedside rendering care. The average time for inpatient hospital care codes include the time in which the physician reviews the medical record, examines the patient, charts notes, and communicates with other professionals and the patient’s family. It does not include time spent off the patient’s floor.

2. Does split/shared billing require the physician to see the patient and perform any part of the E/M?

Billing visits split/shared under the physician’s NPI requires the physician to have a face to face visit with the patient and personally document the portion of the service performed.

1. Will Medicare make payment for more than one initial hospital visit during the same admission performed by providers of the same specialty but different group practices?

No, Medicare does not reimburse multiple visits to providers of the same specialty within the same and/or different group practices. Medicare will reimburse multiple visits to physicians from different groups and different specialties, or physicians of different specialties within the same group practice. 

2. Does Medicare allow an initial hospital care on a day following an office visit?

Medicare pays both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission.

3. If we decide to admit from the office, should we bill the office visit and the lowest initial admission code?

No, if admitting the patient after an office visit, the initial hospital code would include all work performed by the physician in all sites. The initial hospital care day would be the only code reported if the physician performed a face-to-face visit in the hospital setting as well as the office.

4. Will Medicare pay for more than one initial hospital visit per hospital admission?

In the inpatient hospital setting and nursing facility setting, any physician and/or qualified non-physician practitioner who perform an initial evaluation may bill an initial hospital care visit code (99221 – 99223) or nursing facility care visit code (99304 – 99306), where appropriate. Medicare will only pay for one initial hospital care day per patient, per admission, per specialty.

5. Am I permitted to bill an initial hospital visit (for a consultation) even though I have an established relationship with the patient?

Yes. The concept of a new or established patient does not apply to inpatient hospital care days. Practitioners can use these codes for the first visit to an inpatient even if they have an established relationship with the patient.

6. Will Medicare allow an initial hospital care visit and a discharge to be paid on the same day?

When the patient is admitted to inpatient hospital care for less than eight hours on the same date, then initial hospital care (99221–99223) shall be reported by the provider. The hospital discharge day management service (99238 or 99239) shall not be reported for this scenario.

When a patient is admitted to inpatient initial hospital care and discharged on a different calendar date, the physician shall report an initial hospital care (99221–99223) and a hospital discharge day management service (99238 or 99239).

When a patient has been admitted to inpatient hospital care for a minimum of eight hours but less than 24 hours and discharged on the same calendar date, observation or inpatient hospital care services (including admission and discharge services), from code range 99234-99236, shall be reported.

7. One of the cardiologists from our group saw a patient in the hospital this morning. The patient worsened and needed to be seen later in the day. Can the first cardiologist bill an initial and the other cardiologist bill a subsequent visit.

No. Medicare does not pay two E/M visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day. Physicians (same group/same specialty) must bill and be paid as a single physician. Select a level of service representative of the combined visits and submit appropriate code.

8. Where can I find guidelines for initial hospital visits?

The guidelines for initial hospital visits can be found in the CMS IOM Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.9.

1. Is it a requirement to document the past, family, and social history (PFSH) for subsequent in-hospital visits?

For the categories of subsequent hospital care and subsequent nursing facility care, the current procedural terminology requires only an "interval" history. It is not necessary to record information about the PFSH. An "interval" history would include changes from the previous encounter to the present.

2. Can two different providers bill a subsequent hospital visit on the same day?

Subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. Physicians of different specialties may each report a subsequent hospital visit on the same day.

1. Can any physician bill the hospital discharge day management service?

Only the attending provider of record reports the discharge day management service.

2. How do I bill discharge day management when I discharged my patient on day one, but dictated my notes on day 2? Which day do I use for submitting the claim?

Bill the discharge day management with the actual discharge date. The medical records should clearly state the date of the actual discharge and dictated the following date.

CMS IOM Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.9.2

3. How are hospital discharge services reported?

The CPT manual explains, hospital discharge day management codes are to be utilized to report all services provided to a patient on the date of discharge, if other than the initial date of inpatient status.

To report services for a patient who is admitted inpatient and discharged on the same date, use codes 99234-99236 for observation or inpatient hospital care including admission and discharge of the patient on the same date. To report concurrent care services provided by an individual other than the practitioner performing the discharge day management service, use subsequent hospital care codes (99231-99233) on the day of discharge.

Note: For observation care discharge, use 99217; for nursing facility care discharge, use 99315, 99316.

4. What date is used when reporting a hospital discharge day management service?

A hospital discharge day management service (99238 or 99239) is a face-to-face E/M service between the attending provider and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner (NPP), even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient, per hospital stay.

Only the attending provider of record reports the discharge day management service.

Medicare pays for the paperwork of patient discharge day management through the pre-and post-service work of an E/M service.

5. Will Medicare pay for multiple hospital discharges on the same calendar day for the same patient?

No, only one discharge is permitted per patient admission.

To report concurrent care services provided by an individual other than the practitioner performing the discharge day management service, use subsequent hospital care codes (99231-99233) on the day of discharge.

6. What if the attending provider of record is not available to discharge a patient but his partner from his same group is?

It is also acceptable for physicians of the same specialty from the same group practice to discharge. Physicians of the same group with the same specialty are recognized as a single physician.

7. Who is paid for the hospital discharge management and death pronouncement?

Only the physician who personally performs pronouncement of death shall bill for the face-to-face hospital discharge day management service (99238 or 99239). The date of the pronouncement shall reflect the calendar date on the day the service was performed, even if paperwork is delayed to a subsequent date.

8. How do you bill for a patient who expired?

According to established legal principles, an individual is not deceased until there has been official pronouncement of death. Therefore, an individual expired at the time of pronounced of death by a legally authorized person who is usually a physician. Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services.

9. Why are services for hospital discharge day management being reduced from 99239 to 99238?

Services may be reduced when the medical records do not contain the time the physician spent with the patient. Hospital discharge day management codes 99238 (30 minutes or less) and 99239 (more than 30 minutes) are time based so it is imperative that medical documentation reflect total time spent by a physician during the discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, (even if the time spent by the physician on that date is not continuous), instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.

10. If my patient is admitted at 11 pm and discharge at 9 am the next morning, can I bill the admission and discharge codes 99234-99236?

Admission and discharge codes (99234-99236) are only billable when admission and discharge occur on the same calendar day and includes more than 8 hours but less than 24 hours. Each calendar day is billable as long as a face to face visit is done on both.

11. Does Medicare allow a hospital discharge management and nursing facility admission to be paid when rendered on same day?

When a patient is discharged from a hospital and admitted to a nursing facility on same day, Medicare may pay the hospital discharge code (code 99238 or 99239) in addition to a nursing facility admission code when billed by the same physician with the same date of service.

12. Rather than obtaining copies of pages from the hospital record, is it sufficient to send a statement that I spent more than 30 minutes in my discharge activities, as long as I give the specifics regarding patient name, health insurance claim number, and date of service?

While this information is necessary when billing 99239, it is essential to send the visit note or discharge summary from that date of service, in order to substantiate the service billed.

CMS IOM Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.9.2

1. Are 'incident to' services excluded in skilled nursing facilities (SNFs)?

Where a physician establishes an office in a SNF/NF, the “incident to” services and requirements are confined to this part of the facility designated as his/her office. “Incident to” E/M visits, provided in a facility setting, are not payable under the physician fee schedule for Medicare Part B. Thus, visits performed outside the designated “office” area in the SNF/NF would be subject to the coverage and payment rules applicable to the SNF/NF setting and should not be reported using CPT codes for office or other outpatient visits or place of service code 11.

CMS Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.13E

2. Can a qualified non-physician practitioner perform the initial visit in a skilled nursing facility and/or nursing facility?

The initial visit in a SNF or nursing facility (NF) procedure codes 99304-99306, must be performed by a physician except as otherwise permitted (42 C.F.R. 483.40 (c) (4)). The initial visit is defined as the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.

Further, per the long-term care regulations at 42 CFR 483.40 (c)(4) and (e)(2), the physician may not delegate a task that the physician must personally perform. Therefore, the physician may not delegate the initial visit in a SNF (place of service 31). This also applies to the NF (place of service 32) with one exception.

A qualified non-physician practitioner such as a nurse practitioner, physician assistant, or a clinical nurse specialist, who is not employed by the facility, may perform the initial visit when the State law permits.

CMS Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.13

3. If I provide a service, under arrangement to a SNF that is subject to SNF consolidated billing, what rate do we charge the SNF for the service?

The SNF and provider/supplier agree to contractual terms prior to services provided. As part of this agreement, the SNF and the supplier (could be an ambulance) negotiate the terms and amount of payment. According to the CMS Publication 100-04, Claims Processing Manual, Chapter 6, section 10.4.1, “Medicare does not prescribe the actual terms of the SNF’s relationship with its suppliers (such as the specific amount or timing of payment by the SNF), which are to be arrived at through direct negotiation between the parties to the agreement.”

4. Our physician provided a chest X-ray (code 71010) to a patient who is a resident of a SNF. How do we bill the chest x-ray?

If the patient is in a SNF covered Part A stay, the physician/practitioner bills the professional component of the chest x-ray to Part B with modifier -26. The technical component of diagnostic tests/services is subject to SNF consolidated billing and billable by only the SNF. In this instance, the physician/practitioner looks to the SNF for payment of the technical component.

To determine whether a service/procedure is/is not subject to SNF consolidated billing, please refer to the Part B MAC update files housed on the CMS SNF Consolidated Billing Part B MAC File Expansion web page.

5. If a physician/practitioner sees a SNF resident in their office for an office visit, is the office visit billed by the physician/practitioner and if so, what place of service code is used?

The professional services that the physician/practitioner performs personally are not subject to SNF consolidated billing. Therefore, if the patient was in the office, the physician/practitioner bills the office visit to Part B with place of service code 11 (office). However, services performed ‘incident to’ the physician/practitioner services are subject to SNF consolidated billing and, therefore, billed by the SNF. In this instance, the physician/practitioner looks to the SNF for payment.

To determine whether a service/procedure is/is not subject to SNF consolidated billing, please refer to the Part B MAC update files housed on the CMS SNF Consolidated Billing Part B MAC File Expansion web page.

6. Must a physician/practitioner (or any other entity) have an agreement with the SNF for services that are subject to consolidated billing?

It is a best practice for a SNF to enter into an arrangement with any outside provider/supplier from which the SNF's residents receive "bundled" services (services subject to SNF consolidated billing). The absence of an agreement does not relieve the SNF of its overall responsibility to furnish directly or under arrangement for all services that are subject to the consolidated billing requirement.

For additional information, please visit the CMS Best Practices web page.

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/ 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?

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-to-face 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.