November 24, 2023 | By Brenda Edwards, CPC, CDEO, CPB, CPC-I, CEMC, CRC, CMRS, CMCS
If you are like me and have been coding for over half of your life, we have seen many changes. I remember the 1980s when all we had were the code books without the illustrations or descriptive additions that are included with today’s code sets. We didn’t have electronic tools (heck, we didn’t have computers!) What about the cryptic local and national coverage determinations? We had to navigate with very little help. We have so many great resources and assistance now, including code books, software, payors, and other vendors that help to keep our stress level in a semi-normal range.
This audit tip is a summary of the recent webinar I gave for NAMAS. So, for some of you, this is a refresher of that talk. You may have noticed that the CMS Evaluation and Management (E/M) Guidelines located in the Medicare Learning Network were unavailable this past year. Since the information in it was tied to the previous E/M guidelines, it needed a major update to reflect the inpatient, observation, and care facility changes. That update occurred in August, and if you have not had time to review it, you really need to.
CMS has made changes in their writing style, making it more user-friendly. Gone are the days of “overarching criterion” and other formal language. They have embraced “we” and “you,” and think about it the providers are the audience since they are performing the services, so “you” makes it more personal to the providers.
Let’s drill down a bit on the information found in this document.
- Tip boxes that offer coding advice on different scenarios, including billing for prolonged services, split/shared visits, and critical care.
- After the Table of Contents, a page containing links to the documents used in creating the updates.
- Red font indicates substantive content updates that take up most of the first 14 pages. That is the meat and potatoes where you will want to grab a highlighter and mark up!
Medical Record Documentation
This is a great addition to see CMS and CPT® (for the most part) in agreement!
- The CPT® E/M Guidelines for MDM apply. For all E/M visits, the history and physical exam must meet the descriptions in the code descriptors, but they don’t affect visit level selection. This supports the need for our providers to document a medically appropriate history and examination.
- When time is used to select the visit level, the provider must provide services for the full-time. Refer to CPT® for the full list of services included in time.
- The general CPT rule about the midpoint for certain timed services doesn’t apply.
- When time is used to support billing the E/M visit, document the medical record with the time spent with the patient using a start and stop time or the total time. Another good point of clarification is that a specific (as possible) time needs to be included when billing based on time.
Initial Inpatient and Observation Services
- It is important to remember that when we talk about hospital services, it is not limited to inpatient codes. For example, observation services by somebody other than the admitting provider will use outpatient E/M codes.
- Observation Care Following Initiation of Observation Services: A single service is counted when a continuous service occurs that spans the transition of two calendar dates. Report the date the patient encounter begins and all of the time can be applied to the date of service as long as it is continuous. Remember that only the treating provider bills using observation codes. Other providers will report the appropriate outpatient service codes.
- Initial Inpatient or Observation Care on the Day Following Visit: MACs pay both visits when a patient is in the office on 1 day and admitted to the hospital as an inpatient or observation care on the next day. This applies even if fewer than 24 hours have elapsed between the visit and the admission for hospital inpatient or placement in observation care.
- Initial Inpatient or Observation Care and Discharge on Same Day: A table is included with clear explanations of how to report based on the time the patient was admitted.
Critical Care Services
- Beginning January 1, 2022, use the AMA CPT language for the definition of critical care visits (99291 and 99292).
- 99291 can only be reported once per date, even if the time spent isn’t continuous.
- 99292 for each additional 30-minute time increment cannot be reported until 104 minutes have been spent with the patient (74 minutes for 99291 and a full 30 minutes for 99292).
- When multiple providers in the same specialty and the same group provide care concurrently to the same patient on the same date, the primary provider should report their time with 99291, and the other providers will report 99292 for additional time intervals.
Split/Shared Services
- One point to mention that is not in this booklet is the 2024 Medicare Final Rule has indicated that split/shared services will continue to be reported with either MDM or time for the next calendar year. This is the verbiage from CMS: “substantive portion means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision-making.”
Back to the E/M Booklet:
- In 2023, when 1 of the 3 key parts (the elements of the new MDM table) is the substantive portion, the physician or NPP who bills the services must perform the key part in its entirety to bill the services.
- Critical care services can be reported as split/shared when the physician or NPP who provides more than 50% of the total time spent with the patient bills for the visit.
- Only distinct time can reported for split/shared E/M services. Time spent when the providers jointly meet or discuss the patient can only be counted for one of the providers.
Prolonged Services
- CMS uses different codes to report prolonged services than what CPT® uses.
- G0316 Prolonged hospital inpatient or observation care evaluation and management service
- G0317 Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service
- G0318 Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service
- Report prolonged services with the highest level of E/M in the applicable categories.
- The prolonged time must be at least 15 minutes beyond the total time of the primary service (99223, 99233, 99236, 99306, 99310, 99345, 99350).
- A table with detailed information is included in the booklet.
This is not all-inclusive of what you will find in the CMS E/M Guidelines Booklet. A thorough review of the full document is recommended to ensure your practice is documenting, billing, and coding appropriately. The document can be found here: 08.28.2023_MLN906764_E_M_Services_Guide_2023_08_508-1.pdf
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
- Check out Brenda’s recent webinar on these Inpatient E/M Updates for 2024 here!
