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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана
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• Comprehensive: A general multisystem examination or a complete examination
of a single organ system and other symptomatic or related body area(s) or organ
system(s).
P. Winn and L. Gelman
Medical Decision Making
There are several factors that can increase the complexity of medical decision making. These include:
• Number and complexity of problem(s) addressed at the encounter.
• Number of management options that are considered and selected.
• Amount and complexity of medical data and other relevant information that has
been reviewed and analyzed.
• Risk of signicant complications, and/or morbidity and/or mortality, in addition
to comorbidities and their respective severity and how these can impact patient
management options.
There are four levels of complexity of medical decision making
• Straightforward: Minimal number of diagnoses or management options; minimal or no data to be reviewed; minimal risk of complications, morbidity, and
mortality.
• Low complexity: Limited number of diagnoses or management options; limited
amount or complexity of data to be reviewed; low risk of complications, morbid-
ity, and mortality.
• Moderate complexity: Multiple diagnoses or management options; moderate
amount of complexity of data to be reviewed; moderate risk of complications,
morbidity, and mortality.
• High complexity: Extensive diagnoses or management options; extensive amount
or complexity of data to be reviewed; high risk of complications, morbidity, and
mortality.
Visit Time
As of January 1, 2023, the time allocated to an E/M visit code (see Tables 2 and
3) can now be used to determine the level of service. Remember that the docu-
mentation of each encounter must be of sufcient detail to support the E/M
code. Visit time can be used to determine the level of an E/M service if counsel-
ling and coordination of care are greater than 50% of the total time spent with a
patient or resident. The prolonged service E/M codes are described later in the
chapter.
Documentation andCoding
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Initial SNF or NF visit codes
Table 2
99304
• 99304 (REQUIRES THREE OF THREE E&M COMPONENTS)
– DETAILED OR COMPREHENSIVE HX
– DETAILED OR COMPREHENSIVE EXAM
– MEDICAL DECISION MAKING:
• STRAIGHTFORWARD LOW
– 25min must be met or exceeded
• USED FOR:
– INITIAL ADMISSION/READMISSION
– Usually, the problem(s) requiring admission are of low severity
99305
• 99305 (REQUIRES THREE OF THREE E&M COMPONENTS)
– COMPREHENSIVE HX
– COMPREHENSIVE EXAM
– MEDICAL DECISION MAKING:
• Moderate
– 35min must be met or exceeded
• USED FOR
– INITIAL ADMISSION/READMISSION
– Usually, the problem(s) requiring admission are of moderate severity
99306
• 99306 (REQUIRES THREE OF THREE E&M COMPONENTS)
– COMPREHENSIVE HX
– COMPREHENSIVE EXAM
– MEDICAL DECISION MAKING:
• HIGH
– 45min must be met or exceeded
• USED FOR:
– INITIAL ADMISSION/READMISSION
– Usually, the problem(s) requiring admission are of high severity
Note: for services 60min or longer, use prolonged services code 993X0
331
99305 99306
Table 3
Subsequent SNF or NF visit codes: 99307–99310
99307
• 99307 (REQUIRES TWO OF THREE E&M COMPONENTS)
– PROBLEM FOCUSED HX
– PROBLEM FOCUSED EXAM
– MEDICAL DECISION MAKING:
• STRAIGHTFORWARD
– 10min must be met or exceeded
• USED FOR
– PATIENT STABLE, RECOVERING, OR IMPROVING
– “ROUTINE/REGULATORY” VISIT
(continued)
332
Table 3 (continued)
99308
• 99308 (REQUIRES TWO OF THREE E&M COMPONENTS)
– EXPANDED PROBLEM FOCUSED HX
– EXPANDED PROBLEM FOCUSED EXAM
– MEDICAL DECISION MAKING:
• Low
– 15min must be met or exceeded
• USED FOR:
– PATIENT RESPONDING INADEQUATELY TO RX OR DEVELOPED MINOR
COMPLICATION
– “ROUTINE/REGULATORY” VISIT
99309
• 99309 (REQUIRES TWO OF THREE E&M COMPONENTS)
– DETAILED HX
– DETAILED EXAM
– MEDICAL DECISION MAKING:
• Moderate
– 30min must be met or exceeded
• USED FOR
– PATIENT DEVELOPED SIGNIFICANT COMPLICATION OR SIGNIFICANT NEW
PROBLEM
– “ROUTINE/REGULATORY” VISIT
99310
• 99310 (REQUIRES TWO OF THREE E&M COMPONENTS)
– COMPREHENSIVE HX
– COMPREHENSIVE EXAM
– MEDICAL DECISION MAKING:
• HIGH
– 45min must be met or exceeded
• USED FOR
– The patient may be unstable or may have developed a signicant new problem
requiring immediate physician attention
Note: for services 60min or longer, use prolonged service codes 993X0
P. Winn and L. Gelman
Coding andBilling forSkilled Nursing andNon-Skilled
Nursing Facility Visits
The E/M service code selected is based upon fullling the requirements of the individual CPT code. Each patient visit must always meet the requirement as to medical
necessity. Having provided the service and properly documented the care, selection
of the appropriate CPT code is usually straightforward.
For practitioner services in nursing facilities there are four categories of
service codes
• Initial Nursing Facility Care (services provided on admission to the SNF or NF
for the initial comprehensive assessment): 99304, 99305, 99306. The patient’s
attending physician of record must append the modier “AI” to the bill when
performing initial visits.
Documentation andCoding
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333
• Subsequent Nursing Facility Care (services provided subsequent to or prior to
the initial comprehensive assessment): 99307, 99308, 99309, 99310.
• Services provided for discharge: 99315 or 99316 (based on time 30min or less,
more than 30min).
• Services provided for the annual health evaluation: 99318 (This code has been
deleted as of January 1, 2023).
Note that all these codes apply to both new and established patients.
The appropriate Initial Nursing Facility Care code is determined by the exten-
siveness and complexity of the components of the E/M service provided; with the
most comprehensive service being billed at level 99306 (see Table 2). Use of the
initial codes require that all three E/M components be performed (history, physical, medical decision making). These codes are used for the initial admission (or
readmission, if the patient has previously resided in the nursing facility and had
been discharged, i.e., no bed hold). Note that the initial codes are related to the
place of service to which a patient is being admitted. For clarication, note that if a
patient from your practice is being admitted to a NF/SNF, it is not a subsequent
patient visit, but an initial visit to that facility and should be coded as an initial visit.
The Subsequent Nursing Facility care codes are reviewed in Table3. The appro-
priate subsequent care code is determined by the complexity of the components of
the E/M service provided, with the most complex and comprehensive services being
coded at the 99310 level that is associated with a high risk of complications, morbidity and/or mortality. When billing for subsequent care, only two of the three E/M
components need be performed, though optimal medical care would entail that all
three components be performed and documented.
The codes for services provided upon discharge from a SNF or NF are 99315
and 99316 (see Table 4). For these discharge services, the differentiation of the
appropriate code is determined by the total time spent performing all of the tasks
and services required for the patient’s discharge (nal exam, instructions for continuing care, preparation of discharge records, prescriptions, referral forms and
communication with practitioners who are to provide follow-up care for the patient
after discharge). It is important to remember that these discharge visit codes, as all
the other visit codes, require a face-to-face visit. If the visit is performed on a day
different than the actual day of discharge, the date of service for billing should be
the actual date of the visit. The discharge code can be used for a visit when a
Table 4 SNF or NF discharge visit codes: 99315 or 99316
• 99315—30 MIN OR LESS DURATION OF TIME
• 99316—MORE THAN 30 MIN DURATION OF TIME
• USED FOR:
– FINAL EXAM
– INSTRUCTIONS FOR CONTINUING CARE
– PREPARATION OF DISCHARGE RECORDS
– PRESCRIPTIONS
– REFERRAL FORMS
– COMMUNICATIONS WITH AFTER-DISCHARGE PROVIDERS
334
P. Winn and L. Gelman
resident has died; however it is only billable if the physician fullls the requirement
of a face-to-face visit and pronounces the death of the patient!
CMS requires that any E/M code for a SNF visit be modied with the Place of
Service Code modier “31” and that for a NF visit with the Place of Service Code
modier “32.”
Other Coding Issues inNursing Facilities
Consultations
A specialist/consultant or a primary care physician may perform consultations in a
nursing or skilled nursing facility. A billable consultation requires a request/order
from the attending physician of record who is overseeing the care of the patient. As
of 2010, the initial consultation visit is billed using the nursing facility initial
assessment E/M codes (99304–99306). The patient’s principal physician of record
must append the modier “AI” to the bill when performing initial visit to differentiate the attending initial visit from a consultant’s initial visit for which no modier
is needed. The principal “physician of record” is identied by Medicare as the
physician who oversees the patient’s overall care at the facility. Follow-up visits by
the consultant are billed using the subsequent nursing facility visit codes
(99307–99310).
Hospice Care
When a patient is receiving care under the Medicare Hospice Benet, there are
additional guidelines for billing for provided services that depends on whether the
physician has a relationship with the hospice and whether that care is related to the
terminal illness or not (see Table5). However, physicians should ask their Medicare
Administrative Contractor (formerly called Medicare Fiscal Intermediary or Carrier)
to verify whom to bill for physician services related to the terminal diagnosis (i.e.,
whether the hospice or Medicare Part B). Usually if the patient’s attending
Table 5 Billing for services on patients receiving the medicare hospice benet
• For care not related to terminal illness
– Bill Medicare Part B—Modier GW
• For care related to terminal illness (check with your Medicare Administrative Contractor)
– If the physician is not associated with the hospice
• Bill Medicare Part B—Modier GV
– If the physician is associated with/employed by the hospice
• Bill hospice unless services are covered by a contract or agreement with hospice
Documentation andCoding
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Table 6 Group practice
• Same group—same specialty
– Bill and be paid as though they were single physician
– One E/M code per day
– Can combine same day visits and submit appropriate code
– Unrelated problems: can submit different bills; documentation critical
• Same group—different specialty
– Bill and be paid without regard to membership in group
335
physician is also the medical director of the hospice from which the patient is
receiving hospice services, then that physician should bill the hospice for services
rendered. If not the hospice medical director, then the attending physician should
bill Medicare Part B.Also, for a consultant who performs a follow-up ofce visit
related to the patient’s hospice diagnosis, then the physician should bill the hospice
on an agreed negotiated reimbursement. Often this is not done and the visit erroneously billed to Medicare Part B.
Physicians inGroup Practice
In certain circumstances, providers of a group practice of the same specialty may
bill for services provided to a patient on the same day (see Table 6 on Group
Practice).
Multi-Site Same Day Visits
The only instances in which Medicare will pay for two different services provided
by the same physician for the same patient on the same day at different sites of
service is for hospital discharge (99238, 99239) and the nursing facility admission
(99304, 99305, 33906). Documentation must meet the E/M requirements for each
site of service. It is not acceptable that the nursing facility admission H and P state
“see hospital discharge H and P.”
Split or Shared Visits
Previously Medicare did not recognize split or shared E/M visits at the nursing
facility and thus would not reimburse for them. However, starting in 2022 CMS now
permits such visits for new and establish patients, for initial and subsequent visits,
for critical care services, prolonged E/M visits, and SNF E/M visits (except those
visits that are required to be done by the attending physician).
336
P. Winn and L. Gelman
“Incident To” Services
“Incident to” services provided in the nursing facility are not recognized by
Medicare and will not be reimbursed. However, if the physician has established an
ofce in the nursing facility (a discrete space that the physician rents and uses for
patient care visits), “incident to” services provided in that discrete ofce space are
billable and thus reimbursable. In this case, the “incident to” services should be
billed utilizing the ofce E/M codes.
Prolonged Face-to-Face Service Codes (99417, 993X0)
The E/M codes for prolonged service with direct patient contact (99354–99357)
have been deleted as of January 1, 2023. For prolonged evaluation and management
services on the date of an outpatient service or a private home or residence, use code
99417. While for prolonged E/M services on the date of a face-to-face nursing
home service, use code 993X0.
Prolonged Non-Face-to-Face Service Codes (99358, 99359)
These service codes are used when a prolonged service is provided on a date
other than the date of the face-to-face visit (E/M encounter) that occurred with
the patient and/or family/caregiver. Use of these codes must be related to the faceto-face patient care visit that previously occurred, regardless of the place of
service.
These codes are used for prolonged physician services without direct patient
contact such as speaking to family members or extraordinary chart/medical
record review. Time spent must be documented and include what was reviewed.
These codes are not an add-on code and must be performed on a different day
and be directly related to the previous face-to-face visit, are to be performed on
a single day and time, not accumulated over several days; and cannot overlap
with chronic care management codes, may not be reimbursable. Using these pro-
longed service codes does not guarantee reimbursement. For clarication on their
use and reimbursement contact the CMS Physician Fee Schedule web page, the
CMS Division of Practitioner Services, or your local Medicare Administrative
Contractor.
Code 99358 is used to report the rst 60min of the prolonged visit code on a
given date regardless of place of service and only used once per date. Code 99359
is used to report each additional 30min beyond the rst 60min and to report the
nal 15–30min of the prolonged given service date. An initial service time less than
30min is not reportable nor re-imbursed.
Documentation andCoding
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337
Chronic Care Management Services
Some practitioners have queried whether Medicare would allow billing (and thus
receive reimbursement) for CCM services for patients who reside in nursing and
assisted living facilities. If a CCM service is billed and payment received it does not
necessarily indicate such services are covered. Erroneous payment, once detected,
could potentially put practitioners at risk of fraud. Accordingly, be in contact for
those sources previously suggested for clarication in the previous section.
Annual Nursing Facility Resident Assessment (AWVs):
(G0438, G0439)
Are Medicare Annual Wellness Visits (AWV) able to be performed and reimbursed
for residents in nursing facilities? For residents in assisted living facilities? AWVs
entail a “personalized preventive plan of service.” As such could this assessment be
performed at the nursing or assisted living facility? Or at a physician’s communitybased clinic? It is suggested you contact CMS or the local Medicare Administrative
Contractor for clarication. If allowable, remember that you must meet all the
required components of the initial AWV and subsequent AWV.
Telehealth Services
During the COVID-19 pandemic CMS authorized the use of telehealth for nursing
facility and domiciliary (assisted living) facilities for both newly admitted and
established patients. For nursing facility residents, telehealth visits were limited to
once every 14days. There is a concern that emergency use authorization under
COVID-19 will be rescinded once the COVID-19 pandemic Public Health
Emergency (PHE) is declared to have ended. CMS is proposing that nursing facility
initial service (99304–99306) will be removed from the allowable telehealth list
151days after the PHE ends, stating that all regulatory visits must be done in person, given that the initial visit is considered a regulatory visit.
Visits by Qualied Nonphysician Practitioners
Nonphysician practitioners (NPP) include nurse practitioners (NP), physician assistants (PA), and clinical nurse specialists (CNS). All E/M visits must be performed
within their State scope of practice and licensure requirements. Any federal and state
requirements for physician collaboration and physician supervision must be met.
Refer to Table 7 for the Federal regulations related to which services may be
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Table 7 Nonphysician practitioner services
Order
SNF
PA, NP,
and CNS
employed
by facility
PA, NP,
and CNS
not a
facility
employee
NF
NP, CNS,
and PA
employed
by facility
NP, CNS,
and PA not
a facility
employee
Admission
to
treatment
admit
orders
N N N Y
N N N Y
N N N N Y Y Y
Y Y Y Y Y Y Y
Initial
comprehensive
visit
Other
required
visits
(alternate)
(alternate)
P. Winn and L. Gelman
Other
medically
necessary
visits
Y Y N
Y Y Y
Other
medically
necessary
orders
Certication,
recertication
provided by various NPPs as related to their employment status and care setting.
Note that these requirements may vary from one state to another and can change
over time.
Services Provided intheNF or SNF That Are Not Reimbursable
by Medicare
Care plan oversight, telephone calls, and medical team conferences (interdisciplinary team meetings) are not reimbursable and prolonged services without a face-toface visit may not be reimbursable. Contact your local Medicare Administrative
Contractor for clarication.
Coding andBilling forAssisted Living Facilities
Levels of E/M services for assisted living facilities are determined by the same rst
three key components. See Table8. These billing codes are used for assisted living
facilities, group homes, custodial care facilities, and residential substance abuse
facilities. It is important to use the correct place of service code for each of these
venues (13, 14, 33, and 55, respectively). Note that as of January 1, 2023 the service
Documentation andCoding
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Table 8 Private home/residence and assisted living visit codes (as of January 1, 2023)
Initial care Subsequent care
• 99341–15′ • 99347–20′
• 99342–30′ • 99348–30′
• 99343—Deleted′ • 99349–40′
• 99344–60′ • 99350–60′
• 99345–75′ • 75′ or longer use add on 99417
• 90′ or longer use add on 99417
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E/M codes 99324–99328 and 99334–99337 have been deleted. Accordingly, the
home visit E/M codes are now to be used for assisted living visits: 99341, 99342,
99344, and 99345 for new patient visits and 99347–99350 for established patient visits.
Coding andBilling forHome Visits
Visit services provided in the patient’s home are billed using the same set of codes
as listed in Table 8 and follow the same parameters for E/M intensity, and also
guided by the same duration time of service with place of service code 12.
Summary
Proper documentation and coding of patient visits, irrespective of place of service, is
a skill that practitioners must attain and maintain. Documentation must be thorough,
appropriate to the condition(s) being assessed and truthful. The extensiveness of the
history, physical examination, and medial decision making must support the chosen
visit code. Time for the visit can now guide the choice of a given code. Over- coding
(and thus over-billing) can be considered fraud, which can result in a dire situation
for practitioners that could include payback to Medicare, nancial penalties, and
criminal changes. When unsure whether to use a specic visit code, contact the CMS
Division of Practitioner Services or your local Medicare Administrative Contractor.
Pearls for the Practitioner
• Medical necessity and fullling the requirements of the individual CPT code are
necessary for choosing the level of an E/M code.
• Appropriate and thorough documentation in the medical record must support the
chosen level of service E/M code.
• The extensiveness of the history, physical examination, and the complexity of
medical decision making must be linked to the presenting complaint(s) or clinical situation.
• The three key components of any E/M code are history, physical examination,
and medical decision making.
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