Table of Contents CPT HCPCS Modifiers NCCI Multiple procedures Fee calculation Global surgical payment Diagnosis coding A physician sees a patient in the office or treats a patient with a fracture in the emergency department and wants to get paid for this service. That shouldn’t be too much to ask, should it? The coding and reimbursement system in the United States is anything but simple and easy. This billing … [Read more...]
CMS Proposed Changes in the 2019 Physician Fee Schedule Rule | Webinar
Recorded August 16, 2018 Some Fee Schedule rules are almost boring, but not this year! CMS is proposing significant changes to the payment of and documentation for new and established patient visits. This will be a sea change for most groups, particularly groups that use RVUs for physician compensation or that have coders coding all E/M services. CMS is proposing an effective date of January 1, 2019, but asking for comments about … [Read more...]
CMS proposes significant changes to E/M requirements
By now, you’ve read the headlines that CMS is proposing major changes to both the documentation requirements for new and established patient visits and the payment structure for the services. I’ll try to go beyond the headlines in this post, and tell you what CMS is proposing. Of course, we know that CMS puts together proposals every year for the payment policy for the coming year. Right now we are in a comment period for these policies. … [Read more...]
Not all emergency surgery should be coded at the highest level | E/M Services and MDM
Surgeons sometimes think that the E/M service on the date of every emergency surgery is the highest level E/M. 99205 or 99285 or 99223. When I teach E/M level in general surgery, few topics cause as much disagreement as what level of service the surgeon can bill for the E/M service for a patient before emergency surgery. Of course, the first task is to select the correct category of code. Or, as one physician said to me, “Just tell me … [Read more...]
Coding home visits | Cheat Sheet
Use this reference guide to select a level of service for new and established patient home visits, based on the key components or time. Relevant Search Terms: 1995 Exam, 1997 Exam, Medical decision making, home visits, HPI, ROS, selecting a code based on time, CPT codes for home visits, E/M codes for home visits, home visit CPT codes, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 … [Read more...]
Are changes coming to the E/M documentation guidelines?
Do you remember that CMS is talking about changing the documentation requirements for E/M services? If it slipped your mind in the course of your busy work weeks, you can read my article about that here. CMS E/M listening call March 21, CMS held its E/M listening session and I joined in. First you might want to know what did CMS say? Well, not much. They listened. They posed a series of questions and listened to the responses from people on … [Read more...]
What does the decision to perform a minor procedure really mean?
I received this question recently and want to share it with you. “Since the decision to perform a minor procedure is included in the payment for the minor procedure, does this mean we can never bill an E/M and a procedure on the same day for the same condition?” It doesn’t mean you can never bill an E/M and a minor procedure on the same day. You can bill an E/M and a minor procedure (procedure with 0 or 10 global days) on the same calendar … [Read more...]
Let’s go to the source! Should this visit be downcoded?
A physician asked me this question: “As an interventionalist, a good part of my visit is spent not only explaining patients conditions to them but discussing various diagnostic/therapeutic procedures, the risks and benefits and whether to consider surgery. Recently I had a 99215 challenged. I documented >40min more than 50% in face-to-face counseling and detailed all of the matters discussed. I was told it should be down-coded to 99214 … [Read more...]
Determining new patient vs. established patient | CPT Rules
Question: A physician wrote: “We have a cosmetic treatment center that is separate from our surgical clinic. I have seen a patient in the cosmetic treatment center solely for administration of Botox (self-pay). We did not bill her insurance. Now she would like to see me in the surgical clinic regarding having some suspicious moles removed. Should I bill the E/M code as a new patient or as an established patient? Answer: Following CPT … [Read more...]
Can I bill Hospital H&P for pre-op?
Question: Sometimes, a patient who is scheduled for surgery comes back to the office for an H&P and informed consent. Can I bill for that? Answer: No. Once the patient is scheduled for surgery, an E/M visit for the purpose of a hospital H&P and informed consent may not be billed. The CPT Assistant described this in their May 2009 journal. Related resources: Global Surgery Billing Guide Surgical Modifiers … [Read more...]
To Credit or Not to Credit: Auditing E/M Services
Recorded September 21, 2017 When it comes to auditing E/M services, there’s black, white and a whole lot of gray. Reasonable auditors can disagree. So, how can auditors and coders accurately select a level of service? First, by thorough knowledge of the Guidelines themselves. Second, by developing a set of internal, defensible policies that address the gray areas of the Guidelines. Prior to the webinar, participants should re-read the … [Read more...]
Everything you want (and need) to know about E/M services
Evaluation and Management (E/M) services account for 30% of the revenue paid by Medicare for all physician services. For many specialties, E/M codes account for 60-70% of total revenue. Maximum reimbursement depends on understanding the rules related to these services. The goal of this presentation is to teach these rules for office E/M services with the goal of revenue enhancement and compliance. 60 minutes Agenda for this webinar … [Read more...]
CMS is seeking comments about updating E/M service definitions
I hope you’re sitting down, because there is big news! The proposed physician fee schedule rule was released in mid July and includes a section about E/M (evaluation and management services). CMS is asking for comments about changing the documentation guidelines! The current guidelines were developed in 1995 and 1997, prior to the adoption of electronic health records by most medical practices. Let me start this article by quoting the proposed … [Read more...]
Billing Guide – Critical Care Services
Critical care is a complex service provided to a patient who has vital organ failure or to prevent further life threatening deterioration of the patient’s condition. The CPT coding rules and the CMS reimbursement rules can be confusing. The payment for this time-based service is high, and payers frequently do pre or post payment review. Table of Contents: What is critical care Other E/M services and critical care on the … [Read more...]
7 sure fire ways to owe the government $4 million in fines and repayments | Coding Compliance
Most practices aren’t looking to pay the government any money in fines and repayment because of coding errors. Two recent OIG settlements described two practices that did just that. Most practices want to avoid this, of course, but some groups seem determined to achieve that outcome. In reviewing both of the settlements, there are some patterns that emerge. And specific activities that can be avoided. The two groups in question were not … [Read more...]
Medical Decision Making | Evaluation and Management Services
Lunch and Learn - May 2017 Medical Decision Making is the third key component of evaluation and management services. MDM has three components: The number of diagnoses or treatment options The amount of data that the clinician reviewed The morbidity and mortality from the Table of Risk This short video discusses the requirements for selecting the level of medical decision making, including information on the point system … [Read more...]
Documenting Exam|Evaluation and Management Services
Lunch and Learn - April 2017 Exam is the second key component of evaluation and management services. This short video discusses the requirements for documenting exam, including a review of the 1995 and 1997 Exam guidelines, and what you must document for high level visits. The printable companion resource will be a helpful cheat sheet for providers, coders and auditors. Browse more coding resources: Everyday Coding E/M … [Read more...]
Pessary Cleaning and Re-insertion
Question: Can we bill code 57160 when a patient comes in for a pessary cleaning? Answer: No, report an E/M service based on the key components. 57160 is for the initial fitting and insertion of the pessary. Read this post for more information about pessary billing and coding. See more Everyday Coding Q & A's Related Resources: Key Components of E/M Services, Pessary Billing and Coding … [Read more...]
Documenting History |Evaluation and Management Services
Lunch and Learn - March 2017 What does a clinician need to document in the history? Is it okay to say, "non-contributory"? What if the medical assistant takes the HPI and the physician or nurse practitioner notes that it was reviewed? This short video addresses the documentation guidelines for the History component of evaluation and management services including, HPI (history of present illness), ROS (review of systems) and PFSH (past … [Read more...]
Meatloaf says, “2 out of 3 ain’t bad” | E/M Documentation Guidelines
Question: When selecting an E/M service for an established patient, does medical decision making need to be one of the determining factors? Answer: Not according to CMS. Recently, when I was explaining the two of three rule to a physician he said, “Just like the Meatloaf song.” I hadn’t ever considered Meatloaf and the Documentation Guidelines together. Medical necessity and the nature of the presenting problem need to be considered … [Read more...]