A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states:
For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.
Q. If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?
A. It is mandatory that the physician’s documentation clearly indicates that the forms have been reviewed by him/her, and that any follow-up on positive and pertinent negative responses is documented.
Q. Can I document the most clinically relevant systems and then say “all other systems reviewed are negative” in order to qualify for a complete (10 system) ROS?
A. This would be allowed if all other systems were, indeed, reviewed and are negative, and if a complete ROS is medically necessary.
Q. If the patient’s medical record indicates that the PFSH is “non-contributing” with regard to the patient’s condition, does this documentation support that the PFSH was reviewed?
A. If the record indicates that the patient’s past, family, and social history (PFSH) is “non-contributing,” it may be inferred that the practitioner did not ask the patient about his or her PFSH. However, if the practitioner has reviewed the patient’s PFSH, it should be documented in the medical record.
Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”
A. Yes -- when referring to previous notes, specific information must be given regarding when and where.
Q. If I document allergies, do I get credit for an element of past medical history, or is this counted as part of the review of systems (Allergic/Immunologic) (or both)?
A. The single element of allergies would only be counted once (for either past medical history or review of systems).
Q. Can I use elements of History of Present Illness (HPI) as elements of Review of Systems (ROS) and have them both count, or is it one or the other? For example if the patient has chest pain which is “associated with shortness of breath” in the HPI, does this also count as an element of respiratory ROS?
A. The same element would only be counted once. In the example given, there are two different elements indicated (shortness of breath and chest pain), so this would count for both HPI and ROS, respectively.
Q. Do you use the numeric conversion for the 1995 E/M guidelines (i.e., problem focused exam: one system and/or body area, expanded problem focused exam: 2-4 organ systems and/or body areas, detailed exam: 5-7 body areas and/or organ systems, comprehensive: 8 organ systems)?
A. The 1995 guidelines do not specify exact numbers -- problem focused implies one system/area, and only comprehensive has a numeric indication (8).
Q. During an evaluation and management visit, what constitutes “prescription drug management?”
A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”
Q. What is required to get credit for prescription drug management? Do I have to stop, start or change a medication dosage, or can I get credit for making the decision to continue a specific medication?
A. Credit is given as long as the documentation clearly indicates that decision-making took place in regard to the medication(s).
Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.
Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.
Q. In medical-decision making, how does one determine further work-up under “number of diagnoses”?
A. A key element of the medical-decision making category includes management decisions made by the physician to determine a diagnosis and treatment. Evidence of further work-up within documentation would include: indicating a problem is worsening/probable and/or listing possible management options, advice sought, referrals or consultations, and the initiation of or change in treatment.
Q. What is the definition of “self-limited” or “minor” problem vs. “new stable problem?”
A. A new, stable problem is a new problem, which is not worsening. A self-limited or minor problem is of less severity and would be expected to run its course uneventfully.
Q. Can I refer to someone else’s dictated note and get credit for those parts of the history I reviewed?
A. Yes - review of “old records” is part of the medical decision-making process.
Q. If I review my own previous notes and summarize my findings, would I get credit for “review and summation of old records”?
A. No, credit would not be given for summarizing one’s own previous records.
Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”
A. Yes -- when referring to previous notes, specific information must be given regarding when and where.
Q. When calculating the medical decision-making, are problems defined as “old” or “new” relative to the patient or to the physician?
A. Regarding the medical decision-making component, the designations of “old” and “new” are relative to the physician.
Q. What does a “self-limited or minor problem” mean? Can you please give some examples?
A. A self-limited or minor problem is one in which the resolution is expected to be fairly rapid, with minimal medical intervention. Examples would be a cold or an insect bite.
Q. If a patient is seen in the emergency department, then admitted to the hospital, how should this be billed?
A. As stated in the CMS Internet-only Manual:
Contractors 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.
CPT® code 99058 not recognized as a billable service by Medicare program
Q. We treated a patient in the office on an emergency basis. CPT® codes 99212-25 (Office or other outpatient visit, with modifier 25 to indicate a significant, separately identifiable E/M visit on the same date as another procedure), 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) and 51705 (Change of cystostomy tube; simple) were billed. Can we be reimbursed for the office ER code 99058?
A. Current Procedural Terminology® (CPT®) code 99058 is not a recognized service billable to the Medicare program. The services are billed according to the actual level of care provided to the patient. There is no additional reimbursement for disruption of other scheduled office services.
Q. We submitted a claim with HCPCS code 99233 (Subsequent hospital care) to Medicare and it was downcoded to 99232. Upon inquiring why this change was made, we were told levels were compared to levels of other doctors who were seeing the patient on the same day. Is this correct?
A. No, this is not correct.
In order for the Medical Review department to downcode an E/M service, the documentation is reviewed. In this case, the nurse reviewer must have been unable to identify all elements required for the level of care being billed. In all cases, you should review the records you submit to verify if the correct level of care was selected based on the 1995 or 1997 E/M guidelines. If you disagree with the findings, you may request an appeal, wherein a new reviewer will look at the documentation provided.
Are observation codes considered outpatient or inpatient?
Q. Are observation care codes 99224-99226 and 99234-99236 considered outpatient or inpatient codes?
A. The Centers for Medicare and Medicaid Services (CMS) Internet-only manual directly addresses this point by explaining that while a patient is in observation care they are not considered an inpatient of the hospital. These codes (99224-99226 and 99234-99236) are designated as hospital outpatient observation services.
Q. Does the billing physician need to document the time the patient spent in observation care, or the time the physician spent tending to the patient?
A. The time that must be documented relates to the time that the patient is in observation care. Note that the codes selected regarding services furnished during this time are directly related to how long the patient remains in this status.codes (99224-99226 and 99234-99236) are designated as hospital outpatient observation services.
Q. Does the documentation of the time and date that a patient is in observation care pertain to the time during which the patient was admitted to observation care, or does it start at the time that the physician provides services (i.e., completes a history and physical)?
A. Per the Centers for Medicare & Medicaid Services (CMS) Internet-only manual (IOM):
Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order.
Observation time ends when all medically necessary services related to observation care are completed. Specific coding guidelines are given in the IOM, based on the total time during which the patient is admitted for observation care, without regard to when specific services are provided.
Where to find detailed scenarios pertaining to observation care codes
Q. Where can I find information explaining and distinguishing between codes and guidelines pertaining to observation care and/or inpatient admission/discharge?
A. The CMS Internet-only manual provides detailed scenarios pertaining to observation care coding, and guidelines regarding billing/coding for inpatient hospital services.
Physician must document date and time of medical record
Q. In regard to observation care, must a physician document date and time in the medical record, or is the nursing documentation sufficient to verify date and time?
A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states:
For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which Contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter
Observation care vs. time spent tending to the patient
Q. Does the billing physician need to document the time the patient spent in observation care, or the time the physician spent tending to the patient?
A. The time that must be documented relates to the time that the patient is in observation care. Note that the codes
selected regarding services furnished during this time are directly related to how long the patient remains in this status.
Q: What is a split/shared visit? Can you provide an example?
A: A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.
• A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service.
• The physician and NPP both must be in the same group practice or employed by the same employer.
The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non-facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services or procedures.
Common split/shared visit scenarios
• Hospital inpatient/outpatient/emergency room setting:
• When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's Provider Transaction Access Number (PTAN).
• If there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's PTAN.
• Payment will be made at the appropriate physician fee schedule rate based on the PTAN entered on the claim.
• Office/Clinic setting:
• In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s PTAN.
• When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient.
• If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s PTAN, and payment will be made at the appropriate physician fee schedule payment amount.
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