Medicare Claims Processing Manual Chap12

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Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners
Table of Contents
(Rev. 3747, 04-14-17)
(Rev. 3721, 02-24-17)
Transmittals for Chapter 12
10 - General
20 - Medicare Physicians Fee Schedule (MPFS)
20.1 - Method for Computing Fee Schedule Amount
20.2 - Relative Value Units (RVUs)
20.3 - Bundled Services/Supplies
20.4 - Summary of Adjustments to Fee Schedule Computations
20.4.1 - Participating Versus Nonparticipating Differential
20.4.2 - Site of Service Payment Differential
20.4.3 - Assistant at Surgery Services
20.4.4 - Supplies
20.4.5 - Allowable Adjustments
20.4.6 - Payment Due to Unusual Circumstances (Modifiers “-22” and
“-52”)
20.4.7 - Services That Do Not Meet the National Electrical Manufacturers
Association (NEMA) Standard XR-29-2013
20.4.8 - Special Rule to Incentivize Transition from Traditional X-Ray
Imaging to Digital Radiography
20.4.8.1 - Remittance Advice Remark Codes (RARCs), Claim
Adjustment Reason Codes (CARCs), and Medicare Summary
Notice (MSN)
20.5 - No Adjustments in Fee Schedule Amounts
20.6- Update Factor for Fee Schedule Services
20.7 - Comparability of Payment Provision of Delegation of Authority by CMS to
Railroad Retirement Board
20.8 - Payment for Teleradiology Physician Services Purchased by Indian Health
Services (IHS) Providers and Physicians
30 - Correct Coding Policy
30.1 - Digestive System (Codes 40000 - 49999)
30.2 - Urinary and Male Genital Systems (Codes 50010 - 55899)
30.3 - Audiology Sevices
30.4 - Cardiovascular System (Codes 92950-93799)
30.5 - Payment for Codes for Chemotherapy Administration and
Nonchemotherapy Injections and Infusions
30.6 - Evaluation and Management Service Codes - General (Codes
99201 - 99499)
30.6.1 - Selection of Level of Evaluation and Management Service
30.6.1.1 - Initial Preventive Physical Examination (IPPE) and
Annual Wellness Visit (AWV)
30.6.2 - Billing for Medically Necessary Visit on Same Occasion as
Preventive Medicine Service
30.6.3 - Payment for Immunosuppressive Therapy Management
30.6.4 - Evaluation and Management (E/M) Services Furnished Incident to
Physician’s Service by Nonphysician Practitioners
30.6.5 - Physicians in Group Practice
30.6.6 - Payment for Evaluation and Management Services Provided
During Global Period of Surgery
30.6.7 - Payment for Office or Other Outpatient Evaluation and
Management (E/M) Visits (Codes 99201 - 99215)
30.6.8 - Payment for Hospital Observation Services and Observation or
Inpatient Care Services (Including Admission and Discharge Services)
30.6.9 - Payment for Inpatient Hospital Visits - General
30.6.9.1 - Payment for Initial Hospital Care Services and
Observation or Inpatient Care Services (Including Admission and
Discharge Services)
30.6.9.2 - Subsequent Hospital Visits and Hospital Discharge Day
Management Services (Codes 99231 - 99239)
30.6.10 - Consultation Services
30.6.11 - Emergency Department Visits (Codes 99281 - 99288)
30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes
99291 - 99292)
30.6.13 - Nursing Facility Services
30.6.14 - Home Care and Domiciliary Care Visits (Codes 99324 - 99350)
30.6.14.1 - Home Services (Codes 99341 - 99350)
30.6.15 - Prolonged Services and Standby Services (Codes 99354 - 99360)
30.6.15.1 - Prolonged Services With Direct Face-to-Face Patient
Contact Service (ZZZ codes)
30.6.15.2 - Prolonged Services Without Direct Face-to-Face
Patient Contact Service (Codes 99358 - 99359)
30.6.15.3 - Physician Standby Service (Code 99360)
30.6.15.4 - Power Mobility Devices (PMDs) (Code G0372)
30.6.16 - Case Management Services (Codes 99362 and 99371 - 99373)
40 - Surgeons and Global Surgery
40.1 - Definition of a Global Surgical Package
40.2 - Billing Requirements for Global Surgeries
40.3 - Claims Review for Global Surgeries
40.4 - Adjudication of Claims for Global Surgeries
40.5 - Postpayment Issues
40.6 - Claims for Multiple Surgeries
40.7 - Claims for Bilateral Surgeries
40.8 - Claims for Co-Surgeons and Team Surgeons
40.9 - Procedures Billed With Two or More Surgical Modifiers
50 - Payment for Anesthesiology Services
60 - Payment for Pathology Services
70 - Payment Conditions for Radiology Services
80 - Services of Physicians Furnished in Providers or to Patients of Providers
80.1 - Coverage of Physicians’ Services Provided in Comprehensive Outpatient
Rehabilitation Facility
80.2 - Rural Health Clinic and Federally Qualified Health Center Services
80.3 - Unusual Travel (CPT Code 99082)
90 - Physicians Practicing in Special Settings
90.1 - Physicians in Federal Hospitals
90.2 - Physician Billing for End-Stage Renal Disease Services
90.2.1 - Inpatient Hospital Visits With Dialysis Patients
90.3 - Physicians’ Services Performed in Ambulatory Surgical Centers (ASC)
90.4 - Billing and Payment in Health Professional Shortage Areas (HPSAs)
90.4.1 - Provider Education
90.4.1.1 - A/B MAC (B) Web Pages
90.4.2 - HPSA Designations
90.4.3 - Claims Coding Requirements
90.4.4 - Payment
90.4.5 - Services Eligible for HPSA and Physician Scarcity Bonus
Payments
90.4.6 - Reserved for Future Use
90.4.7 - Post-payment Review
90.4.8 - Reporting
90.4.9 - HPSA Incentive Payments for Physician Services Rendered in a
Critical Access Hospital
90.4.10 - Administrative and Judicial Review
90.4.11 - Health Professional Shortage Areas (HPSA) Surgical Incentive
Payment Program (HSIP) for Surgical Services Rendered in HPSAs
90.4.11.1 - Overview of the HSIP
90.4.11.2 - HPSA Identification
90.4.11.3 - Coordination with Other Payments
90.4.11.4 -General Surgeon and Surgical Procedure Identification
for Professional Services Paid Under the Physician Fee Schedule
(PFS)
90.4.11.5 - Claims Processing and Payment
90.5 - Billing and Payment in a Physician Scarcity Area
90.5.1 - Provider Education
90.5.2 - Identifying Physician Scarcity Area Locations
90.5.3 - Claims Coding Requirements
90.5.4 - Payment
90.5.5 - Services Eligible for the Physician Scarcity Bonus
90.5.5.1 - Remittance Messages
90.5.6 - Post-payment Review
90.5.7 - Administrative and Judicial Review
90.6 - Indian Health Services (IHS) Provider Payment to Non-IHS Physicians for
Teleradiology Interpretations
90.7 - Bundling of Payments for Services Provided in Wholly Owned and Wholly
Operated Entities (including Physician Practices and Clinics): 3-Day Payment
Window
90.7.1 - Payment Methodology: 3-Day Payment Window in Wholly
Owned or Wholly Operated Entities (including Physician Practices and
Clinics)
100 - Teaching Physician Services
100.1 - Payment for Physician Services in Teaching Settings Under the MPFS
100.1.1 - Evaluation and Management (E/M) Services
100.1.2 - Surgical Procedures
100.1.3 - Psychiatry
100.1.4 - Time-Based Codes
100.1.5 - Other Complex or High-Risk Procedures
100.1.6 - Miscellaneous
100.1.7 - Assistants at Surgery in Teaching Hospitals
100.1.8 - Physician Billing in the Teaching Setting
100.2 - Interns and Residents
110 - Physician Assistant (PA) Services Payment Methodology
110.1 - Global Surgical Payments
110.2 - Limitations for Assistant-at-Surgery Services Furnished by Physician
Assistants
110.3 - Outpatient Mental Health Treatment Limitation
110.4 - PA Billing to the A/B MAC (B)
120 - Nurse Practitioner (NP) And Clinical Nurse Specialist (CNS) Services Payment
Methodology
120.1 - Limitations for Assistant-at-Surgery Services Furnished by Nurse
Practitioners and Clinical Nurse Specialists
120.2 - Outpatient Mental Health Treatment Limitation
120.3 - NP and CNS Billing to the A/B MAC (B)
130 - Nurse-Midwife Services
130.1 - Payment for Certified Nurse-Midwife Services
130.2 - Global Allowances
140 - Qualified Nonphysician Anesthetist Services
140.1 - Qualified Nonphysician Anesthetists
140.2 - Entity or Individual to Whom Fee Schedule is Payable for Qualified
Nonphysician Anesthetists
140.3 - Anesthesia Fee Schedule Payment for Qualified Nonphysician
Anesthetists
140.3.1 - Conversion Factors Used on or After January 1, 1997 for
Qualified Nonphysician Anesthetists
140.3.2 - Anesthesia Time and Calculation of Anesthesia Time Units
140.3.3 - Billing Modifiers
140.3.4 - General Billing Instructions
140.4 - Qualified Nonphysician Anesthetist Special Billing and Payment
Situations
140.4.1 - An Anesthesiologist and Qualified Nonphysician Anesthetist
Work Together
140.4.2 - Qualified Nonphysician Anesthetist and an Anesthesiologist in a
Single Anesthesia Procedure
140.4.3 - Payment for Medical or Surgical Services Furnished by CRNAs
140.4.4 - Conversion Factors for Anesthesia Services of Qualified
Nonphysician Anesthetists Furnished on or After January 1, 1992
140.5-- Payment for Anesthesia Services Furnished by a Teaching CRNA
150 - Clinical Social Worker (CSW) Services
160 - Independent Psychologist Services
160.1 - Payment
170 - Clinical Psychologist Services
170.1 - Payment
180 - Care Plan Oversight Services
180.1 - Care Plan Oversight Billing Requirements
190 - Medicare Payment for Telehealth Services
190.1 - Background
190.2 - Eligibility Criteria
190.3 - List of Medicare Telehealth Services
190.3.1 - Telehealth Consultation Services, Emergency Department or
Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits
190.3.2 - Telehealth Consultation Services, Emergency Department or
Initial Inpatient Defined
190.3.3 - Follow-Up Inpatient Telehealth Consultations Defined
190.3.4 – Payment for ESRD-Related Services as a Telehealth Service
190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent
Nursing Facility Care Services as Telehealth Services
190.3.6 – Payment for Diabetes Self-Management Training (DSMT) as a
Telehealth Service
190.4 - Conditions of Payment
190.5 - Originating Site Facility Fee Payment Methodology
190.6 - Payment Methodology for Physician/Practitioner at the Distant Site
190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners
190.6.2 - Exception for Store and Forward (Non-Interactive) Telehealth
190.7 - A/B MAC (B) Editing of Telehealth Claims
200 - Allergy Testing and Immunotherapy
210 - Outpatient Mental Health Treatment Limitation
210.1 - Application of the Limitation
220 Chiropractic Services
230 - Primary Care Incentive Payment Program (PCIP)
230.1 - Definition of Primary Care Practitioners and Primary Care Services
230.2 - Coordination with Other Payments
230.3 - Claims Processing and Payment
10 - General
(Rev. 1, 10-01-03)
B3-2020
This chapter provides claims processing instructions for physician and nonphysician
practitioner services.
Most physician services are paid according to the Medicare Physician Fee Schedule.
Section 20 below offers additional information on the fee schedule application. Chapter
23 includes the fee schedule format and payment localities, and identifies services that
are paid at reasonable charge rather than based on the fee schedule. In addition:
• Chapter 13 describes billing and payment for radiology services.
• Chapter 16 outlines billing and payment under the laboratory fee schedule.
• Chapter 17 provides a description of billing and payment for drugs.
• Chapter 18 describes billing and payment for preventive services and screening
tests.
The Medicare Manual Pub 100-1, Medicare General Information, Eligibility, and
Entitlement Manual, Chapter 5, provides definitions for the following:
Physician;
Doctors of Medicine and Osteopathy;
Dentists;
Doctors of Podiatric Medicine;
Optometrists;
Chiropractors (but only for spinal manipulation); and
Interns and Residents.
The Medicare Benefit Policy Manual, Chapter 15, provides coverage policy for the
following services.
Telephone services;
Consultations;
Patient initiated second opinions; and
Concurrent care.
Chapter 26 provides guidance on completing and submitting Medicare claims.
20 - Medicare Physicians Fee Schedule (MPFS)
(Rev. 1, 10-01-03)
B3-15000
A/B MACs (B) pay for physicians’ services furnished on or after January 1, 1992, on the
basis of a fee schedule. The Medicare allowed charge for such physicians’ services is the
lower of the actual charge or the fee schedule amount. The Medicare payment is 80
percent of the allowed charge after the deductible is met.
Chapter 23 provides a list of physicians’ services payable based on the Medicare
Physician Fee Schedule (MPFS).
20.1 - Method for Computing Fee Schedule Amount
(Rev. 1, 10-01-03)
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee
schedule amount. For example, input from the American Academy of Ophthalmology
has led to alterations in the supplies and equipment used in the computation of the fee
schedule for selected procedures. Likewise, new research has changed the payments
made for physical and occupational therapy. The CMS provides the updated fee
schedules to A/B MACs (B) on an annual basis. The sections below introduce the
formulas used for fee schedule computations.
A. Formula
The fully implemented resource-based MPFS amount for a given service can be
computed by using the formula below:
MPFS Amount = [(RVUw x GPCIw) + (RVUpe x GPCIpe) +
(RVUm x GPCIm)] x CF
Where:
RVUw equals a relative value for physician work,
RVUpe equals a relative value for practice expense, and
RVUm refers to a relative value for malpractice.
In order to consider geographic differences in each payment locality, three geographic
practice cost indices (GPCIs) are included in the core formula:
• A GPCI for physician work (GPCIw),
• A GPCI for practice expense (GPCIpe), and
• A GPCI for malpractice (GPCIm).
The above variables capture the efforts and productivity of the physician, his/her
individualized costs for staff and for productivity-enhancing technology and materials.
The applicable national conversion factor (CF) is then used in the computation of every
MPFS amount.
The national conversion factors are:
2002 - $36.1992
2001 - $38.2581
2000 - $36.6137
1999 - $34.7315
1998 - $36.6873
1997 - $40.9603 (Surgical); $33.8454 (Nonsurgical); $35.7671 (Primary Care)
1996 - $40.7986 (Surgical); $34.6296 (Nonsurgical); $35.4173 (Primary Care)
1995 - $39.447 (Surgical); $34.616 (Nonsurgical); $36.382 (Primary Care)
1994 - $35.158 (Surgical); $32.905 (Nonsurgical); $33.718 (Primary Care)
1993 - $31.926 (Surgical); $31,249 (Nonsurgical);
1992 - $31.001
For the years 1999 through 2002, payments attributable to practice expenses transitioned
from charge-based amounts to resource-based practice expense RVUs. The CMS used
the following transition formula to calculate the practice expense RVUs.
1999 - 75 percent of charged-based RVUs and 25 percent of the resource-based
RVUs.
2000 - 50 percent of the charge-based RVUs and 50 percent of the resource-based
RVUs.
2001 - 25 percent of the charge-based RVUs and 75 percent of the resource-based
RVUs.
2002 - 100 percent of the resource-based RVUs.
As the tabular display introduced earlier indicates, CMS has calculated separate facility
and nonfacility resource-based practice expense RVUs.
B. Example of Computation of Fee Schedule Amount
The following example further clarifies the computation of a fee schedule amount.
Background Example
Nationwide, cardiovascular disease has retained its position as a primary cause of
morbidity and mortality. Currently, cardiovascular disease affects approximately 61.8
million Americans. Cardiovascular disease is responsible for over 40 percent of all
deaths in the United States. However, 84.3 percent of those deaths are persons age 65
and above.
Organ transplantation is one modality that has been used in the treatment of
cardiovascular disease. Currently over 2,000 persons per year receive a heart transplant.
However, another 2,300 persons are on the waiting list. Because of the disparity between
the demand and supply of organs, mechanical heart valves are now covered under
Medicare.
Sample Computation of Fee Schedule
Patients fitted with a mechanical heart valve require intensive home international
normalized ratio (INR) monitoring by his/her physician. Physician services required may
include instructions on demonstrations to the patient regarding the use and maintenance
of the INR monitor, instructions regarding the use of a blood sample for reporting home
INR test results, and full confirmation that the client can competently complete the
required self-testing.
Assumptions
RVUw = 0
Given the nature of the example, the physician would, under product code G0248, not be
allowed to assign work RVUs.
RVUm = .01
However, the treatment of the patient with a mechanical heart carries a level of risk.
RVUpe = 2.92
Based upon a relatively intense level of staff time for an RN/LRN, or MN, as well as a
supply list that includes a relatively sophisticated home INR monitor, batteries,
educational materials, test strips and other materials, the RVUpe can be assigned a value
of 2.92.
The above values require modification by regionally based values for work, practice, and
malpractice. If the city is assumed to be Birmingham, Alabama, the values below can be
assigned based upon current data.
GPCIw = 0.994
GPCIpe = 0.912
GPCIm = 0.927
The above indices suggest that the index in Birmingham is .6 percent below the national
norm for physician work intensity, 8.8 percent below the national norm for practice
expenses, and 7.3 percent below the national norm for malpractice.
If the assumption is made that the nonfacility payment for a home visit is $166.52, the
full fee schedule payment can be computed through substitution into the formula.
Payment = (RVUw x GPCIw + (RVUpe x GPCIpe) + RVUm + GPCIm x
physician fee schedule payment.
Payment = (0 x .994) + (2.92 x .927) + (.01 x .912) x $166.52 =
Payment = (0) + (2.70684) + (.00912) x 166.52
Payment = $452.26166 or $452.26 when rounded to the nearest cent.
The above example is purely illustrative. The CMS completes all calculations and
provides A/B MACs (B) with final fee schedules for each locality via the Medicare
Physicians’ Fee Schedule Database (MPFSDB). Localities used to pay services under the
MPFS are listed in Chapter 23.
20.2 - Relative Value Units (RVUs)
(Rev. 1, 10-01-03)
Resource-based practice expenses relative value units (RVUs) comprise the core of
physician fees paid under Medicare Part B payment policies. The CMS provides A/B
MACs (B) with the fee schedule RVUs for all services except the following:
Those with local codes;
Those with national codes for which national relative values have not been
established;
Those requiring “By Report” payment or A/B MAC (B) pricing; and
Those that are not included in the definition of physicians’ services.
For services with national codes but for which national relative values have not been
provided, A/B MACs (B) must establish local relative values (to be multiplied, in the
MCS system, by the national CF), as appropriate, or establish a flat local payment
amount. A/B MACs (B) may choose between these options.
The “By Report” services (with national codes or modifiers) include services with codes
ending in 99, team surgery services, unusual services, pricing of the technical component
for positron emission tomography reduced services, and radio nuclide codes A4641 and
79900. The status indicators of the Medicare fee schedule database identify these
specific national codes and modifiers that A/B MACs (B) are to continue to pay on a “By
Report” basis. A/B MACs (B) may not establish RVUs for them. Similarly, A/B MACs
(B) may not establish RVUs for “By Report” services with local codes or modifiers.
Additionally, A/B MACs (B) do not establish fees for noncovered services or for services
always bundled into another service. The MPFSDB identifies noncovered national codes
and codes that are always bundled.
A. Diagnostic Procedures and Other Codes With Professional and Technical
Components
For diagnostic procedure codes and other codes describing services with both
professional and technical components, relative values are provided for the global
service, the professional component, and the technical component. The CMS makes the
determination of which HCPCS codes fall into this category.
B. No Special RVUs for Limited License Practitioners
There are no special RVUs for limited license physicians, e.g., optometrists and
podiatrists. The fee schedule RVUs apply to a service regardless of whether a medical
doctor, doctor of osteopathy, or limited license physician performs the service. A/B
MACs (B) may not restrict either physicians, independently practicing physical
therapists, and/or other providers of covered services by the use of these codes.
20.3 - Bundled Services/Supplies
(Rev. 147, 04-23-04)
There are a number of services/supplies that are covered under Medicare and that have
HCPCS codes, but they are services for which Medicare bundles payment into the
payment for other related services. If A/B MACs (B) receive a claim that is solely for a
service or supply that must be mandatorily bundled, the claim for payment should be
denied by the A/B MAC (B).
A. Routinely Bundled
Separate payment is never made for routinely bundled services and supplies. The CMS
has provided RVUs for many of the bundled services/supplies. However, the RVUs are
not for Medicare payment use. A/B MACs (B) may not establish their own relative
values for these services.
B. Injection Services
Injection services (codes 90782, 90783, 90784, 90788, and 90799) included in the fee
schedule are not paid for separately if the physician is paid for any other physician fee
schedule service rendered at the same time. A/B MACs (B) must pay separately for those
injection services only if no other physician fee schedule service is being paid. In either
case, the drug is separately payable. If, for example, code 99211 is billed with an
injection service, pay only for code 99211 and the separately payable drug. (See section
30.6.7.D.) Injection services that are immunizations with hepatitis B, pneumococcal, and
influenza vaccines are not included in the fee schedule and are paid under the drug
pricing methodology as described in Chapter 17.
C. Global Surgical Packages
The MPFSDB lists the global charge period applicable to surgical procedures.
D. Intra-Operative and/or Duplicate Procedures
Chapter 23 and §30 of this chapter describe the correct coding initiative (CCI) and
policies to detect improper coding and duplicate procedures.
E. EKG Interpretations
For services provided between January 1, 1992, and December 31, 1993, A/B MACs (B)
must not make separate payment for EKG interpretations performed or ordered as part of,
or in conjunction with, visit or consultation services. The EKG interpretation codes that
are bundled in this way are 93000, 93010, 93040, and 93042. Virtually, all EKGs are
performed as part of or ordered in conjunction with a visit, including a hospital visit.
If the global code is billed for, i.e., codes 93000 or 93040, A/B MACs (B) should assume
that the EKG interpretation was performed or ordered as part of a visit or consultation.
Therefore, they make separate payment for the tracing only portion of the service, i.e.,
code 93005 for 93000 and code 93041 for 93040. When the A/B MAC (B) makes this
assumption in processing a claim, they include a message to that effect on the Medicare
Summary Notice (MSN).
For services provided on or after January 1, 1994, A/B MACs (B) make separate payment
for an EKG interpretation.
20.4 - Summary of Adjustments to Fee Schedule Computations
(Rev. 1931, Issued: 03-12-10, Effective: 06-14-10, Implementation: 06-14-10)
For services prior to January 1, 1994, A/B MACs (B) computed the fee schedule amount
for every service. Through 1995, the fee schedule amount is the transition fee schedule
amount. For services after 1995, CMS computes and provides the fee schedule amount
for every service discussed above.
Certain adjustments are made in order to arrive at the final fee schedule amount.
Those adjustments are:
• Participating versus nonparticipating differential;
• Reduction for re-operations;
• Site of service payment adjustment;
• Multiple surgeries;
• Bilateral surgery;
• Anti-Markup Payment Limitation;
• Provider providing less than global fee package;
• Assistant at surgery;
• Two surgeons/surgical team; and
• Supplies.
20.4.1 - Participating Versus Nonparticipating Differential
(Rev. 1, 10-01-03)
B3-15032
For services/supplies rendered prior to January 1, 1994, the amounts allowed to
nonparticipating physicians, under the fee schedule may not exceed 95 percent of the
participating fee schedule amount. Payments to other entities under the fee schedule
(physiological and independent laboratories, physical and occupational therapists,
portable x-ray suppliers, etc.) are not subject to this differential unless the entities are
billing for a physician’s professional service. When a nonparticipating nonphysician is
billing for a physician’s professional service, Medicare’s allowance could not exceed 95
percent of the fee schedule amount.
For services/supplies rendered on or after January 1, 1994, payments to any
nonparticipant may not exceed 95 percent of the fee schedule amount or other payment
basis for the service/supply. This five percent reduction applies not only to
nonparticipating physicians, physician assistants, nurse midwives, and clinical nurse
specialists but also to entities such as nonparticipating portable x-ray suppliers,
independently practicing physical and occupational therapists, audiologists, and other
diagnostic facilities. Furthermore, these nonparticipating entities including physicians,
are subject to the five percent reduction not only when they bill for services paid for
under the physician fee schedule, but also when they bill for services that are legally
billable under the physician fee schedule, but which are based upon alternative payment
methodologies. As of January 1, 9994 and beyond, the services/supplies included in this
latter category are drugs and biologicals provided incident to physicians services. The
payment basis for these drugs and biologicals is the lower of the average wholesale price
(AWP) or the estimated acquisition cost (EAC). Therefore, the Medicare payment
allowance for “incident to” drugs and biologicals billed by and a nonparticipant cannot
exceed 95 percent of whichever is lower than the AWP or the EAC.
20.4.2 - Site of Service Payment Differential
(Rev. 3586, Issued: 08-12-16, Effective: 01-01-17, Implementation: 01-03-17)
Under the Medicare Physician Fee schedule (MPFS), some procedures have separate
rates for physicians’ services when provided in facility and nonfacility settings. The
CMS furnishes both rates in the MPFSDB update.
The rate, facility or nonfacility, that a physician service is paid under the MPFS is
determined by the Place of service (POS) code that is used to identify the setting where
the beneficiary received the face-to-face encounter with the physician, nonphysician
practitioner (NPP) or other supplier. In general, the POS code reflects the actual place
where the beneficiary receives the face-to-face service and determines whether the
facility or nonfacility payment rate is paid. However, for a service rendered to a patient
who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes
19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the
beneficiary occurred. For the professional component (PC) of diagnostic tests, the
facility and nonfacility payment rates are the same – irrespective of the POS code on the
claim. See chapter 13, section 150 of this manual for POS instructions for the PC and
technical component of diagnostic tests.
The list of settings where a physician’s services are paid at the facility rate include:
• Telehealth (POS 02);
• Outpatient Hospital-Off campus (POS code 19);
• Inpatient Hospital (POS code 21);
• Outpatient Hospital-On campus (POS code 22);
• Emergency Room-Hospital (POS code 23);
• Medicare-participating ambulatory surgical center (ASC) for a HCPCS code
included on the ASC approved list of procedures (POS code 24);
• Medicare-participating ASC for a procedure not on the ASC list of approved
procedures with dates of service on or after January 1, 2008. (POS code 24);
• Military Treatment Facility (POS Code 26);
• Skilled Nursing Facility (SNF) for a Part A resident (POS code 31);
• Hospice – for inpatient care (POS code 34);
• Ambulance – Land (POS code 41);
• Ambulance – Air or Water (POS code 42);
• Inpatient Psychiatric Facility (POS code 51);
• Psychiatric Facility -- Partial Hospitalization (POS code 52);
• Community Mental Health Center (POS code 53);
• Psychiatric Residential Treatment Center (POS code 56); and
• Comprehensive Inpatient Rehabilitation Facility (POS code 61).
Physicians’ services are paid at nonfacility rates for procedures furnished in the following
settings:
• Pharmacy (POS code 01);
• School (POS code 03);
• Homeless Shelter (POS code 04);
• Prison/Correctional Facility (POS code 09);
• Office (POS code 11);
• Home or Private Residence of Patient (POS code 12);
• Assisted Living Facility (POS code 13);
• Group Home (POS code 14);
• Mobile Unit (POS code 15);
• Temporary Lodging (POS code 16);
• Walk-in Retail Health Clinic (POS code 17);
• Urgent Care Facility (POS code 20);
• Birthing Center (POS code 25);
• Nursing Facility and SNFs to Part B residents (POS code 32);
• Custodial Care Facility (POS code 33);
• Independent Clinic (POS code 49);
• Federally Qualified Health Center (POS code 50);
• Intermediate Health Care Facility/Mentally Retarded (POS code 54);
• Residential Substance Abuse Treatment Facility (POS code 55);
• Non-Residential Substance Abuse Treatment Facility (POS code 57);
• Mass Immunization Center (POS code 60);
• Comprehensive Outpatient Rehabilitation Facility (POS code 62);
• End-Stage Renal Disease Treatment Facility (POS code 65);
• State or Local Health Clinic (POS code 71);
• Rural Health Clinic (POS code 72);
• Independent Laboratory (POS code 81);and
• Other Place of Service (POS code 99).
See chapter 26, section 10.5 of this manual for the complete listing of the Place of
Service code set, including instructions and special considerations for the application of
certain POS codes under Medicare.
Nonfacility rates are applicable to outpatient rehabilitative therapy procedures, including
those relating to physical therapy, occupational therapy and speech-language pathology,
regardless of whether they are furnished in facility or nonfacility settings. Nonfacility
rates also apply to all comprehensive outpatient rehabilitative facility (CORF) services.
In addition, payment is made at the nonfacility rate for physician services provided to
CORF patients and appropriately billed using POS code 62 for CORF.
20.4.3 - Assistant-at Surgery-Services
(Rev. 2656, Issuance: 02-07-13, Effective: 02-19-13, Implementation: 02-19-13)
For assistant-at-surgery services performed by physicians, the fee schedule amount
equals 16 percent of the amount otherwise applicable for the surgical payment.
A/B MACs (B) may not pay assistants-at-surgery for surgical procedures in which a
physician is used as an assistant-at-surgery in fewer than five percent of the cases for that
procedure nationally. This is determined through manual reviews.
Procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the
AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are
subject to the assistant-at-surgery policy. Accordingly, pay claims for procedures with
these modifiers only if the services of an assistant-at-surgery are authorized.
Medicare’s policies on billing patients in excess of the Medicare allowed amount apply to
assistant-at-surgery services. Physicians who knowingly and willfully violate this
prohibition and bill a beneficiary for an assistant-at-surgery service for these procedures
may be subject to the penalties contained under §1842(j)(2) of the Social Security Act
(the Act.) Penalties vary based on the frequency and seriousness of the violation. Go
to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm and select the relevant section.
20.4.4 - Supplies
(Rev. 1, 10-01-03)
B3-15900.2
A/B MACs (B) make a separate payment for supplies furnished in connection with a
procedure only when one of the two following conditions exists:
A. HCPCS code A4300 is billed in conjunction with the appropriate procedure in the
Medicare Physician Fee Schedule Data Base (place of service is physician’s office).
However, A4550, A4300, and A4263 are no longer separately payable as of 2002.
Supplies have been incorporated into the practice expense RVU for 2002. Thus, no
payment may be made for these supplies for services provided on or after January 1,
2002.
B. The supply is a pharmaceutical or radiopharmaceutical diagnostic imaging agent
(including codes A4641 through A4647); pharmacologic stressing agent (code J1245); or
therapeutic radionuclide (CPT code 79900). Other agents may be used which do not
have an assigned HCPCS code. The procedures performed are:
• Diagnostic radiologic procedures (including diagnostic nuclear medicine)
requiring pharmaceutical or radiopharmaceutical contrast media and/or pharmacologic
stressing agent;
• Other diagnostic tests requiring a pharmacologic stressing agent;
• Clinical brachytherapy procedures (other than remote after-loading high intensity
brachytherapy procedures (CPT codes 77781 through 77784) for which the expendable
source is included in the TC RVUs); or
• Therapeutic nuclear medicine procedures.
Drugs are not supplies, and may be paid incidental to physicians’ services as described in
Chapter 17.
20.4.5 - Allowable Adjustments
(Rev. 1, 10-01-03)
B3-15055
Effective January 1, 2000, the replacement code (CPT 69990) for modifier -20 -
microsurgical techniques requiring the use of operating microscopes may be paid
separately only when submitted with CPT codes:
61304 through 61546
61550 through 61711
62010 through 62100
63081 through 63308
63704 through 63710
64831
64834 through 64836
64840 through 64858
64861 through 64871
64885 through 64891
64905 through 64907.
20.4.6 - Payment Due to Unusual Circumstances (Modifiers “-22” and
“-52”)
(Rev. 1, 10-01-03)
B3-15028
The fees for services represent the average work effort and practice expenses required to
provide a service. For any given procedure code, there could typically be a range of work
effort or practice expense required to provide the service. Thus, A/B MACs (B) may
increase or decrease the payment for a service only under very unusual circumstances
based upon review of medical records and other documentation.
20.4.7 – Services That Do Not Meet the National Electrical
Manufacturers Association (NEMA) Standard XR-29-2013
(Rev. 3402, Issued: 11-06-15, Effective: 01-01-16, Implementation: 01-04-16)
Section 218(a) of the Protecting Access to Medicare Act of 2014 (PAMA) is titled
“Quality Incentives To Promote Patient Safety and Public Health in Computed
Tomography Diagnostic Imaging.” It amends the Social Security Act (SSA) by reducing
payment for the technical component (and the technical component of the global fee) of
the Physician Fee Schedule service (5 percent in 2016 and 15 percent in 2017 and
subsequent years) for computed tomography (CT) services identified by CPT codes
70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706,
74150-74178, 74261-74263, and 75571-75574 furnished using equipment that does not
meet each of the attributes of the National Electrical Manufacturers Association (NEMA)
Standard XR-29-2013, entitled “Standard Attributes on CT Equipment Related to Dose
Optimization and Management.”
The statutory provision requires that information be provided and attested to by a supplier
and a hospital outpatient department that indicates whether an applicable CT service was
furnished that was not consistent with the NEMA CT equipment standard, and that such
information may be included on a claim and may be a modifier. The statutory provision
also provides that such information shall be verified, as appropriate, as part of the
periodic accreditation of suppliers under SSA section 1834(e) and hospitals under SSA
section 1865(a). Any reduced expenditures resulting from this provision are not budget
neutral. To implement this provision, CMS created modifier “CT” (Computed
tomography services furnished using equipment that does not meet each of the attributes
of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard).
Beginning in 2016, claims for CT scans described by above-listed CPT codes (and any
successor codes) that are furnished on non-NEMA Standard XR-29-2013-compliant CT
scans must include modifier “CT” that will result in the applicable payment reduction.
A list of codes subject to the CT modifier will be maintained in the web supporting files
for the annual rule.
Beginning January 1, 2016, a payment reduction of 5 percent applies to the technical
component (and the technical component of the global fee) for Computed Tomography
(CT) services furnished using equipment that is inconsistent with the CT equipment
standard and for which payment is made under the physician fee schedule. This payment
reduction becomes 15 percent beginning January 1, 2017, and after.
20.4.8 - Special Rule to Incentivize Transition from Traditional X-Ray
Imaging to Digital Radiography
(Rev. 3583, Issued: 08-12-16, Effective: 01-01-17, Implementation: 01-03-17)
Section 502(a)(1) of the Consolidated Appropriations Act of 2016 is titled "Medicare
Payment Incentive for the Transition from Traditional X-Ray Imaging to Digital
Radiography and Other Medicare Imaging Payment Provision." It amends the Social
Security Act (SSA) by reducing the payment amounts under the Physician Fee
Schedule by 20 percent for the technical component (and the technical component of the
global fee) of imaging services that are X-rays taken using film, effective January 1,
2017, and after.
Modifier FX (X ray taken using film) was created to implement this
provision. Beginning January 1, 2017, claims for X-rays using film must include
modifier FX, which will result in the applicable payment reduction.
20.4.8.1 - Remittance Advice Remark Codes (RARCs), Claim
Adjustment Reason Codes (CARCs), and Medicare Summary Notice
(MSN)
(Rev. 3583, Issued: 08-12-16, Effective: 01-01-17, Implementation: 01-03-17)
Contractors shall use the following messages when adjusting x-ray radiograph claim lines
that have been reported with the FX modifier:
CARC 237 – Legislated/Regulatory Penalty. At least one Remark Code must be provided
(may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT.)
RARC N775 - Payment adjusted based on x-ray radiograph on film.
MSN 30.1 - The approved amount is based on a special payment method.
20.5 - No Adjustments in Fee Schedule Amounts
(Rev. 1, 10-01-03)
B3-15054
A/B MACs (B) may not make adjustments in fee schedule amounts provided by CMS
for:
• Inherent reasonableness;
• Comparability;
• Multiple visits to nursing homes (i.e., when more than one patient is seen during
the same trip);
• Refractions - If A/B MACs (B) receive a claim for a service that also indicates
that a refraction was done, A/B MACs (B) do not reduce payment for the service.
The CMS has already made the reduction in the fee for refractions provided to
A/B MACs (B);
• HCPCS alpha-numeric modifiers AT (acute treatment), ET (emergency
treatment), LT (left side of body), RT (right side of body), and SF (second
opinion ordered by PRO);
• CPT modifiers -23 (unusual anesthesia), -32 (mandated services), -47 (anesthesia
by surgeon), -76 (repeat procedure by same physician), and -90 (reference
laboratory); and
• A/B MAC (B)-unique local modifiers (HCPCS Level 3 modifiers beginning with
the letters w through z).
20.6- Update Factor for Fee Schedule Services
(Rev. 2464, Issued: 05-04-12, Effective: 10-01-11-MCS/10-01-12-VMS,
Implementation: 10-03-11-MCS, VMS Analysis and Design /10-01-12-VMS
implementation)
The CMS provides updates to the MPFSDB and other fee schedules annually or as otherwise
necessary. Claims processing A/B MACs (B) must maintain at least five full calendar
years of fee schedules and related pricing data (i.e., the current and four prior calendar
years), regardless of the number of updates or pricing periods within those five years.
20.7 - Comparability of Payment Provision of Delegation of Authority
by CMS to Railroad Retirement Board
(Rev. 1, 10-01-03)
B3-15064
The delegation of authority, under which the Railroad Retirement Board (RRB)
administers the Supplementary Medical Insurance Benefits Program for qualified railroad
retirement beneficiaries, requires that:
The Railroad Retirement Board shall take such action as may be necessary to
assure that payments made for services by the A/B MACs (A) it selects will
conform as closely as possible to the payment made for comparable services in
the same locality by an A/B MAC (A) acting for CMS.
The purpose of this comparability of payment is to reduce to the extent possible
disparities between the payments made by the A/B MAC (B) under the RRB delegation
and the payments made by the regular A/B MACs (B) for services or items furnished by
the same physicians, including provider-based physicians, or suppliers. For all services
paid for under the physician fee schedule, A/B MACs (B) under the RRB delegation pay
based on the same fee schedule amount used by the A/B MAC (B).
20.8 - Payment for Teleradiology Physician Services Purchased by the
Indian Health Service (IHS) Providers and Physicians
(Rev. 1643, Issued: 12-05-08, Effective: 01-01-07, Implementation: 03-09-09)
The IHS providers may choose to purchase or otherwise contract with non-IHS
physicians or practitioners for teleradiology interpretations services. These services may
be paid using either contractual reassignment or purchased test methodologies. See
Chapter 19, §120 of this manual for further information.
30 - Correct Coding Policy
(Rev. 1, 10-01-03)
B3-15068
The Correct Coding Initiative was developed to promote national correct coding
methodologies and to control improper coding leading to inappropriate payment in Part B
claims. Refer to Chapter 23 for additional information on the initiative.
The principles for the correct coding policy are:
• The service represents the standard of care in accomplishing the overall
procedure;
• The service is necessary to successfully accomplish the comprehensive procedure.
Failure to perform the service may compromise the success of the procedure; and
• The service does not represent a separately identifiable procedure unrelated to the
comprehensive procedure planned.
For a detailed description of the correct coding policy, refer
to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf.
The CMS as well as many third party payers have adopted the HCPCS/CPT coding
system for use by physicians and others to describe services rendered. The system
contains three levels of codes. Level I contains the American Medical Association’s
Current Procedural Terminology (CPT) numeric codes. Level II contains alpha-numeric
codes primarily for items and services not included in CPT. Level III contains A/B MAC
(B) specific codes that are not included in either Level I or Level II. For a list of CPT
and HCPCS codes refer to the CMS Web site.
The following general coding policies encompass coding principles that are to be applied
in the review of Medicare claims. They are the basis for the correct coding edits that are
installed in the claims processing systems effective January 1, 1996.
A. Coding Based on Standards of Medical/Surgical Practice
All services integral to accomplishing a procedure are considered bundled into that
procedure and, therefore, are considered a component part of the comprehensive code.
Many of these generic activities are common to virtually all procedures and, on other
occasions, some are integral to only a certain group of procedures, but are still essential
to accomplish these particular procedures. Accordingly, it is inappropriate to separately
report these services based on standard medical and surgical principles.
Because many services are unique to individual CPT coding sections, the rationale for
rebundling is described in that particular section of the detailed coding narratives that are
transmitted to A/B MACs (B) periodically.
B. CPT Procedure Code Definition
The format of the CPT manual includes descriptions of procedures, which are, in order to
conserve space, not listed in their entirety for all procedures. The partial description is
indented under the main entry. The main entry then encompasses the portion of the
description preceding the semicolon. The main entry applies to and is a part of all
indented entries, which follow with their codes.
In the course of other procedure descriptions, the code definition specifies other
procedures that are included in this comprehensive code. In addition, a code description
may define a rebundling relationship where one code is a part of another based on the
language used in the descriptor.
C. CPT Coding Manual Instruction/Guideline
Each of the six major subsections include guidelines that are unique to that section.
These directions are not all inclusive of nor limited to, definitions of terms, modifiers,
unlisted procedures or services, special or written reports, details about reporting
separate, and multiple or starred procedures and qualifying circumstances.
D. Coding Services Supplemental to Principal Procedure (Add-On Codes) Code
Generally, these are identified with the statement “list separately in addition to code for
primary procedure” in parentheses, and other times the supplemental code is used only
with certain primary codes, which are parenthetically identified. The reason for these
CPT codes is to enable physicians and others to separately identify a service that is
performed in certain situations as an additional service. Incidental services that are
necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of
an open cholecystectomy) are not separately billed.
E. Separate Procedures
The narrative for many CPT codes includes a parenthetical statement that the procedure
represents a “separate procedure.”
The inclusion of this statement indicates that the procedure, while possible to perform
separately, is generally included in a more comprehensive procedure, and the service is
not to be billed when a related, more comprehensive, service is performed. The “separate
procedure” designation is used with codes in the surgery (CPT codes 10000-69999),
radiology (CPT codes 70000-79999), and medicine (CPT codes 90000-99199) sections.
When a related procedure from the same section, subsection, category, or subcategory is
performed, a code with the designation of “separate procedure” is not to be billed with
the primary procedure.
F. Designation of Sex
Many procedure codes have a sex designation within their narrative. These codes are not
billed with codes having an opposite sex designation because this would reflect a conflict
in sex classification either by the definition of the code descriptions themselves, or by the
fact that the performance of these procedures on the same beneficiary would be
anatomically impossible.
G. Family of Codes
In a family of codes, there are two or more component codes that are not billed separately
because they are included in a more comprehensive code as members of the code family.
Comprehensive codes include certain services that are separately identifiable by other
component codes. The component codes as members of the comprehensive code family
represent parts of the procedure that should not be listed separately when the complete
procedure is done. However, the component codes are considered individually if
performed independently of the complete procedure and if not all the services listed in the
comprehensive codes were rendered to make up the total service.
H. Most Extensive Procedures
When procedures are performed together that are basically the same or performed on the
same site but are qualified by an increased level of complexity, the less extensive
procedure is bundled into the more extensive procedure.
I. Sequential Procedures
An initial approach to a procedure may be followed at the same encounter by a second,
usually more invasive approach. There may be separate CPT codes describing each
service. The second procedure is usually performed because the initial approach was
unsuccessful in accomplishing the medically necessary service. These procedures are
considered “sequential procedures.” Only the CPT code for one of the services, generally
the more invasive service, should be billed.
J. With/Without Procedures
In the CPT manual, there are various procedures that have been separated into two codes
with the definitional difference being “with” versus “without” (e.g., with and without
contrast). Both procedure codes cannot be billed. When done together, the “without”
procedure is bundled into the “with” procedure.
K. Laboratory Panels
When components of a specific organ or disease oriented laboratory panel (e.g., codes
80061 and 80059) or automated multi-channel tests (e.g., codes 80002 - 80019) are billed
separately, they must be bundled into the comprehensive panel or automated multi-
channel test code as appropriate that includes the multiple component tests. The
individual tests that make up a panel or can be performed on an automated multi-channel
test analyzer are not to be separately billed.
L. Mutually Exclusive Procedures
There are numerous procedure codes that are not billed together because they are
mutually exclusive of each other. Mutually exclusive codes are those codes that cannot
reasonably be done in the same session.
An example of a mutually exclusive situation is when the repair of the organ can be
performed by two different methods. One repair method must be chosen to repair the
organ and must be billed. Another example is the billing of an “initial” service and a
“subsequent” service. It is contradictory for a service to be classified as an initial and a
subsequent service at the same time.
CPT codes which are mutually exclusive of one another based either on the CPT
definition or the medical impossibility/improbability that the procedures could be
performed at the same session can be identified as code pairs. These codes are not
necessarily linked to one another with one code narrative describing a more
comprehensive procedure compared to the component code, but can be identified as code
pairs which should not be billed together.
M. Use of Modifiers
When certain component codes or mutually exclusive codes are appropriately furnished,
such as later on the same day or on a different digit or limb, it is appropriate that these
services be reported using a HCPCS code modifier. Such modifiers are modifiers E1 -
E4, FA, F1 - F9, TA, T1 - T9, LT, RT, LC, LD, RC, -58, -78, -79, and -94.
Modifier -59 is not appropriate to use with weekly radiation therapy management codes
(77427) or with evaluation and management services codes (99201 - 99499).
Application of these modifiers prevent erroneous denials of claims for several procedures
performed on different anatomical sites, on different sides of the body, or at different
sessions on the same date of service. The medical record must reflect that the modifier is
being used appropriately to describe separate services.
30.1 - Digestive System (Codes 40000 - 49999)
(Rev. 3368, Issued: 10-09-15, Effective: 01-01-16, Implementation: 01-01-16)
A. Upper Gastrointestinal Endoscopy Including Endoscopic Ultrasound (EUS)
(Code 43259)
If the person performing the original diagnostic endoscopy has access to the EUS and the
clinical situation requires an EUS, the EUS may be done at the same time. The
procedure, diagnostic and EUS, is reported under the same code, CPT 43259. This code
conforms to CPT guidelines for the indented codes. The service represented by the
indented code, in this case code 43259 for EUS, includes the service represented by the
unintended code preceding the list of indented codes. Therefore, when a diagnostic
examination of the upper gastrointestinal tract “including esophagus, stomach, and either
the duodenum or jejunum as appropriate,” includes the use of endoscopic
ultrasonography, the service is reported by a single code, namely 43259.
Interpretation, whether by a radiologist or endoscopist, is reported under CPT code
76975-26. These codes may both be reported on the same day.
B. Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)
An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum
or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid
using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening
colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with
modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database
has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An
incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a
sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted
colonoscopy at a rate that is calculated using one-half the value of the inputs for the
codes.
30.2 - Urinary and Male Genital Systems (Codes 50010 - 55899)
(Rev. 1, 10-01-03)
B3-15200
A. Cystourethroscopy With Ureteral Catheterization (Code 52005)
Code 52005 has a zero in the bilateral field (payment adjustment for bilateral procedure
does not apply) because the basic procedure is an examination of the bladder and urethra
(cystourethroscopy), which are not paired organs. The work RVUs assigned take into
account that it may be necessary to examine and catheterize one or both ureters. No
additional payment is made when the procedure is billed with bilateral modifier “-50.”
Neither is any additional payment made when both ureters are examined and code 52005
is billed with multiple surgery modifier “-51.” It is inappropriate to bill code 52005
twice, once by itself and once with modifier “-51,” when both ureters are examined.
B. Cystourethroscopy With Fulgration and/or Resection of Tumors (Codes 52234,
52235, and 52240)
The descriptors for codes 52234 through 52240 include the language “tumor(s).”
This means that regardless of the number of tumors removed, only one unit of a single
code can be billed on a given date of service. It is inconsistent to allow payment for
removal of a small (code 52234) and a large (code 52240) tumor using two codes when
only one code is allowed for the removal of more than one large tumor. For these three
codes only one unit may be billed for any of these codes, only one of the codes may be
billed, and the billed code reflects the size of the largest tumor removed.
30.3 - Audiology Services
(Rev. 2044, Issued: 09-03-10, Effective: 09-30-10, Implementation: 09-30-10)
Section 1861(ll)(3)of the Social Security Act (the Act) defines “audiology services” as
such hearing and balance assessment services furnished by a qualified audiologist as the
audiologist is legally authorized to perform under State law (or the State regulatory
mechanism provided by State law), as would otherwise by covered if furnished by a
physician. In this section, these hearing and balance assessment services are termed
“audiology services,” regardless of whether they are furnished by an audiologist,
physician, nonphysician practitioner (NPP), or hospital.
Because audiology services are diagnostic tests, when furnished in an office or hospital
outpatient department, they must be furnished by or under the appropriate level of
supervision of a physician as established in 42 CFR 410.32(b)(1) and 410.28(e). If not
personally furnished by a physician, audiologist, or NPP, audiology services must be
performed under direct physician supervision. As specified in 42 CFR 410.32(b)(2)(ii) or
(v), respectively, these services are excepted from physician supervision when they are
personally furnished by a qualified audiologist or performed by a nurse practitioner or
clinical nurse specialist authorized to perform the tests under applicable State laws.
References to technicians apply also to other qualified clinical staff. See Pub. 100-02,
chapter 15, section 80.3.D.
A. Correct Reporting
1. General. Contact the A/B MAC (B) for guidance if the CPT codebook changes the
description of codes mentioned in this section.
Other policies concerning audiological services are found in Pub. 100-02, chapter 15,
section 80.3.
See chapter 26 of this manual for place of service and type of service coding.
Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33), which added
section 1834(k)(5) to (the Act), required that all claims for certain audiology services be
reported using a uniform coding system. CMS chose HCPCS (Healthcare Common
Procedure Coding System) as the coding system for the reporting of these services. This
coding requirement is effective for all claims for audiology services submitted on or after
April 1, 1998.
The BBA also required payment under a prospective payment system for audiology
services. Effective for claims with dates of service on or after January 1, 1999, the
Medicare Physician Fee Schedule (MPFS) became the method of payment for audiology
services furnished in the office setting and for the associated professional services
furnished in physician’s office and hospital outpatient settings.
2. Use of the NPI. For audiologists who are enrolled and bill independently for services
they render, the audiologist’s NPI is required on all claims they submit. For example, in
offices and private practice settings, an enrolled audiologist shall use his or her own NPI
in the rendering loop to bill under the MPFS for the services the audiologist furnished. If
an enrolled audiologist furnishing services to hospital outpatients reassigns his/her
benefits to the hospital, the hospital may bill the A/B MAC (B) for the professional
services of the audiologist under the MPFS using the NPI of the audiologist. If an
audiologist is employed by a hospital but is not enrolled in Medicare, the only payment
for a hospital outpatient audiology service that can be made is the payment to the hospital
for its facility services under the hospital Outpatient Prospective Payment System (OPPS)
or other applicable hospital payment system. No payment can be made under the MPFS
for professional services of an audiologist who is not enrolled.
Audiologists must be enrolled and use their NPI on claims for services they render in
office settings on or after October 1, 2008 (for additional information about enrollment,
refer to Pub. 100-08, Medicare Program Integrity Manual, chapter 15). Before October 1,
2008, the services of audiologists who were not yet enrolled in Medicare were billed by a
physician or group who employed the audiologist. Audiologists shall use the billing
instructions in the Medicare manuals; for example, see this manual, chapter 1, section 30.
See the most recent MPFS for pricing and physician supervision levels for audiology
services: http://www.cms.hhs.gov/PFSlookup/01_Overview.asp#TopOfPage. The NPI
of the supervising physician shall be used to bill audiology services when supervision is
appropriate.
The most recent OPPS pricing for audiology services is available in Addendum B
at: http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage.
B. Billing for Audiology Services
See the CMS Web site at: www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/index.html? and select Audiology from the column on the
left for a listing of all CPT codes for audiology services. For information concerning
codes that are not on the list, and which codes may be billed when furnished by
technicians, A/B MACs (B) shall provide guidance. The Physician Fee Schedule
at http://www.cms.gov/PFSlookup/01_Overview.asp#TopOfPage allows you to search
pricing amounts, various payment policy indicators, RVUs, and GPCIs.
Audiology services may not be billed when the place of service is a comprehensive
outpatient rehabilitation facility (CORF) or a rehabilitation agency.
Audiology services may be furnished and billed by audiologists and, when these services
are furnished by an audiologist, no physician supervision is required.
The interpretation and report shall be written in the medical record by the audiologist,
physician, or NPP who personally furnished any audiology service, or by the physician
who supervised the service. Technicians shall not interpret audiology services, but may
record objective test results of those services they may furnish under direct physician
supervision. Payment for the interpretation and report of the services is included in
payment for all audiology services, and specifically in the professional component if the
audiology service has a professional component/technical component split.
1. Billing under the MPFS for Audiology Services Outside the Facility Setting
The individuals who furnish audiology services in all settings must be qualified to furnish
those services. The qualifications of the individual performing the services must be
consistent with the number, type and complexity of the tests, the abilities of the
individual, and the patient’s ability to interact to produce valid and reliable results. The
physician who supervises and bills for the service is responsible for assuring the
qualifications of the technician, if applicable are appropriate to the test.
a. Professional Skills.
When a professional personally furnishes an audiology service, that individual must
interact with the patient to provide professional skills and be directly involved in
decision-making and clinical judgment during the test.
The skills required when professionals furnish audiology services for payment under the
MPFS are masters or doctoral level skills that involve clinical judgment or assessment
and specialized knowledge and ability including, but not limited to, knowledge of
anatomy and physiology, neurology, psychology, physics, psychometrics, and
interpersonal communication. The interactions of these knowledge bases are required to
attain the clinical expertise for audiology tests. Also required are skills to administer
valid and reliable tests safely, especially when they involve stimulating the auditory
nerve and testing complex brain functions.
Diagnostic audiology services also require skills and judgment to administer and modify
tests, to make informed interpretations about the causes and implications of the test
results in the context of the history and presenting complaints, and to provide both
objective results and professional knowledge to the patient and to the ordering physician.
Examples include, but are not limited to:
• Comparison or consideration of the anatomical or physiological implications of
test results or patient responsiveness to stimuli during the test;
• Development and modification of the test battery and test protocols;
• Clinical judgment, assessment, evaluation, and decision-making;
• Interpretation and reporting observations, in addition to the objective data, that
may influence interpretation of the test outcomes;
• Tests related to implantation of auditory prosthetic devices, central auditory
processing, contralateral masking; and/or
• Tests to identify central auditory processing disorders, tinnitus, or nonorganic
hearing loss.
Audiology codes may be billed under the MPFS by audiologists, physicians, and NPPs
using their own NPI in the rendering loop when those professionals personally furnish the
test. Physicians and NPPs may not bill for these codes when an audiologist has furnished
the service.
b. Technician Skills.
There may be subtests, or parts of a battery of tests, that may be appropriately furnished
by an educated and experienced technician using a specific protocol under the direction
of a supervising physician. These services are identified by A/B MAC (B) determination
as services that do not require professional skills. They may be furnished by a qualified
technician under the direct supervision of a physician, but not under the supervision of an
audiologist or an NPP. The supervising physician is responsible for rendering and
documenting all clinical judgment and for the appropriate provision of the service by the
technician.
A technician may not perform any part of a service that requires professional skills. A
technician also may not perform a global service. For example, a technician may not
interpret test results or engage in clinical decision-making.
c. Professional Component (PC)/Technical Component (TC) Split Codes.
• The PC of a PC/TC split code may be billed by the audiologist, physician, or NPP
who personally furnishes the service. (Note this is also true in the facility setting.)
A physician or NPP may bill for the PC when the physician or NPP furnish the
PC and an (unsupervised) audiologist furnishes and bills for the TC. The PC may
not be billed if a technician furnishes the service. A physician or NPP may not
bill for a PC service furnished by an audiologist.
• The TC of a PC/TC split code may be billed by the audiologist, physician, or NPP
who personally furnishes the service. Physicians may bill the TC for services
furnished by technicians when the technician furnishes the service under the
direct supervision of that physician. Audiologists and NPPs may not bill for the
TC of the service when a technician furnishes the service, even if the technician is
supervised by the NPP or audiologist.
• The “global” service is billed when both the PC and TC of a service are
personally furnished by the same audiologist, physician, or NPP. The global
service may also be billed by a physician, but not an audiologist or NPP, when a
technician furnishes the TC of the service under direct physician supervision and
that physician furnishes the PC, including the interpretation and report.
d. Tests that are Not Described by Specific CPT Codes. Tests that have no appropriate
CPT code may be reported under CPT code 92700 (Unlisted otorhinolaryngological
service or procedure).
e. Tests that are A/B MAC (B)-Priced. For codes valued by A/B MACs (B), the A/B
MAC (B) determines whether and how much, if applicable, to pay for the service. The
A/B MAC (B) sets the requirements for personnel furnishing the tests.
2. Billing for Audiology Services Furnished to Hospital Outpatients.
All codes may be reported for audiology services furnished in the hospital outpatient
setting and, in such cases, the code represents the facility service for the diagnostic test.
All audiology services furnished to hospital outpatients must be billed and paid to the
hospital under the OPPS or other applicable hospital payment system. The hospital bills
its A/B MAC (A) and is paid for the facility resources required to furnish the services,
regardless of whether the service is furnished by a physician, NPP, audiologist, or
technician.
Physicians, NPPs, and audiologists cannot bill and be paid for the TC of PC/TC split
codes when these services are furnished to hospital outpatients. The associated
professional services (represented by the PC or the CPT code for the audiology test which
has no PC/TC split) of an enrolled audiologist, physician, or NPP who has reassigned
benefits may be billed by the hospital to the A/B MAC (B), as appropriate. Alternatively,
if the physician, NPP, or audiologist has not assigned benefits, the professional would bill
his/her A/B MAC (B) for the professional services furnished.
The appropriate revenue code for reporting audiology services is 0470 (Audiology;
General Classification). Providers are required to report a line-item date of service per
revenue code line for audiology services.
3. Billing for Audiology Services Furnished to Skilled Nursing Facility (SNF) Patients.
Payment for the facility resources (including the TC of PC/TC split codes) of audiology
services provided to Part A inpatients of SNFs is included in the PPS rate. For SNFs, if
the beneficiary has Part B but not Part A coverage (e.g., Part A benefits are exhausted),
the SNF may elect to bill for audiology services but is not required to do so. As
explained in Pub. 100-04, chapter 7, section 40.1, since audiology services furnished
during a noncovered SNF stay are not bundled with speech-language pathology services,
payment can be made either to the SNF or to the audiology service provider/supplier.
Audiologists, physicians, and NPPs enrolled in Medicare may bill directly for services
rendered to Medicare beneficiaries who are in a SNF stay that is not covered by Part A
but who have Part B eligibility. Payment is made based on the MPFS, whether on an
institutional or professional claim. For beneficiaries in a noncovered SNF stay,
audiology services are payable under Part B when billed by the SNF on an institutional
claim as type of bill 22X, or when billed directly by the provider or supplier of the
service (the audiologist, physician, or NPP who personally furnishes the test) on a
professional claim. For PC/TC split codes, the SNF may elect to bill for the TC of the
test on an institutional claim but is not required to bill for the service.
C. Implant Processing
Payment for diagnostic testing of implants, such as cochlear, osseointegrated or
brainstem implants, including programming or reprogramming following implantation
surgery is not included in the global fee for the surgery.
The diagnostic analysis of a cochlear implant shall be billed using CPT codes 92601
through 92604.
Osseointegrated prosthetic devices should be billed and paid for under provisions of the
applicable payment system. For example, payment may differ depending upon whether
the device is furnished on an inpatient or outpatient basis, and by a hospital subject to the
OPPS, or by a Critical Access Hospital, physician’s clinic, or a Federally Qualified
Health Center.
D. Aural Rehabilitation Services
General policy for evaluation and treatment of conditions related to the auditory system.
For evaluation of auditory processing disorders and speech-reading or lip-reading by a
speech-language pathologist, use the untimed code 92506 with “1” as the unit of service,
regardless of the duration of the service on a given day. This “always therapy”
evaluation code must be provided by speech-language pathologists according to the
policies in Pub. 100-02, chapter 15, sections 220 and 230. The codes 92620 and 92621
are diagnostic audiological tests and may not be used for SLP services.
For treatment of auditory processing disorders or auditory rehabilitation/auditory training
(including speech-reading or lip-reading), 92507, and 92508 are used to report a single
encounter with “1” as the unit of service, regardless of the duration of the service on a
given day. These codes always represent SLP services. See Pub. 100-02, chapter 15,
sections 220 and 230 for SLP policies. These SLP evaluation and treatment services are
not covered when performed or billed by audiologists, even if they are supervised by
physicians or qualified NPPs.
For evaluation of auditory rehabilitation to instruct the use of residual hearing provided
by an implant or hearing aid related to hearing loss, the timed codes 92626 and 92627 are
used. These are not “always therapy” codes. Evaluation of auditory rehabilitation shall
be appropriately provided and billed by an audiologist or speech-language pathologist.
Also, these services may be provided incident to a physician’s or qualified NPP’s service
by a speech-language pathologist, or personally by a physician or qualified NPP within
their scope of practice. Evaluation of auditory rehabilitation is a covered diagnostic test
when performed and billed by an audiologist and is an SLP evaluation service covered
under the SLP benefit when performed by a speech-language pathologist.
General policies for post implant services.
The services of a speech-language pathologist may be covered for SLP services provided
after implantation of auditory devices. For example, a speech-language pathologist may
provide evaluation and treatment of speech, language, cognition, voice, and auditory
processing using code 92506 and 92507. Use 92626 and 92627 for auditory (aural)
rehabilitation evaluation following cochlear implantation or for other hearing
impairments.
For diagnostic testing of cochlear implants, audiologists use codes 92601, 92602, 92603
and 92604. These services may not be provided by speech-language pathologists or
others, with the exception of physicians and NPPs who may personally provide the
services that are within their scope of practice.
30.4 - Cardiovascular System (Codes 92950-93799)
(Rev. 979, Issued: 06-09-06, Effective: 07-10-06, Implementation: 07-10-06)
A. Echocardiography Contrast Agents
Effective October 1, 2000, physicians may separately bill for contrast agents used in
echocardiography. Physicians should use HCPCS Code A9700 (Supply of Injectable
Contrast Material for Use in Echocardiography, per study). The type of service code is 9.
This code will be A/B MAC (B)-priced.
B. Electronic Analyses of Implantable Cardioverter-defibrillators and Pacemakers
The CPT codes 93731, 93734, 93741 and 93743 are used to report electronic analyses of
single or dual chamber pacemakers and single or dual chamber implantable cardioverter-
defibrillators. In the office, a physician uses a device called a programmer to obtain
information about the status and performance of the device and to evaluate the patient’s
cardiac rhythm and response to the implanted device.
Advances in information technology now enable physicians to evaluate patients with
implanted cardiac devices without requiring the patient to be present in the physician’s
office. Using a manufacturer’s specific monitor/transmitter, a patient can send complete
device data and specific cardiac data to a distant receiving station or secure Internet
server. The electronic analysis of cardiac device data that is remotely obtained provides
immediate and long-term data on the device and clinical data on the patient’s cardiac
functioning equivalent to that obtained during an in-office evaluation. Physicians should
report the electronic analysis of an implanted cardiac device using remotely obtained data
as described above with CPT code 93731, 93734, 93741 or 93743, depending on the type
of cardiac device implanted in the patient.
30.5 - Payment for Codes for Chemotherapy Administration and
Nonchemotherapy Injections and Infusions
(Rev. 968. Issued: 05-26-06; Effective/Implementation Dates: 06-26-06)
A. General
Codes for Chemotherapy administration and nonchemotherapy injections and infusions
include the following three categories of codes in the American Medical Association’s
Current Procedural Terminology (CPT):
1. Hydration;
2. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding
chemotherapy); and
3. Chemotherapy administration.
Physician work related to hydration, injection, and infusion services involves the
affirmation of the treatment plan and the supervision (pursuant to incident to
requirements) of nonphysician clinical staff.
B. Hydration
The hydration codes are used to report a hydration IV infusion which consists of a pre-
packaged fluid and /or electrolytes (e.g. normal saline, D5-1/2 normal saline +30 mg
EqKC1/liter) but are not used to report infusion of drugs or other substances.
C. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding
chemotherapy)
A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration,
is for the administration of substances/drugs. The fluid used to administer the drug (s) is
incidental hydration and is not separately payable.
If performed to facilitate the infusion or injection or hydration, the following services and
items are included and are not separately billable:
1. Use of local anesthesia;
2. IV start;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion; and
5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or
nonchemotherapy injection and infusion service.
If a significant separately identifiable evaluation and management service is performed,
the appropriate E & M code should be reported utilizing modifier 25 in addition to the
chemotherapy administration or nonchemotherapy injection and infusion service. For an
evaluation and management service provided on the same day, a different diagnosis is not
required.
The CPT 2006 includes a parenthetical remark immediately following CPT code 90772
(Therapeutic, prophylactic or diagnostic injection; (specify substance or drug);
subcutaneous or intramuscular.) It states, “Do not report 90772 for injections given
without direct supervision. To report, use 99211.”
This coding guideline does not apply to Medicare patients. If the RN, LPN or other
auxiliary personnel furnishes the injection in the office and the physician is not present in
the office to meet the supervision requirement, which is one of the requirements for
coverage of an incident to service, then the injection is not covered. The physician would
also not report 99211 as this would not be covered as an incident to service.
D. Chemotherapy Administration
Chemotherapy administration codes apply to parenteral administration of non-
radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for
treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions)
or to substances such as monoclonal antibody agents, and other biologic response
modifiers. The following drugs are commonly considered to fall under the category of
monoclonal antibodies: infliximab, rituximab, alemtuzumb, gemtuzumab, and
trastuzumab. Drugs commonly considered to fall under the category of hormonal
antineoplastics include leuprolide acetate and goserelin acetate. The drugs cited are not
intended to be a complete list of drugs that may be administered using the chemotherapy
administration codes. A/B MACs (B) may provide additional guidance as to which drugs
may be considered to be chemotherapy drugs under Medicare.
The administration of anti-anemia drugs and anti-emetic drugs by injection or infusion
for cancer patients is not considered chemotherapy administration.
If performed to facilitate the chemotherapy infusion or injection, the following services
and items are included and are not separately billable:
1. Use of local anesthesia;
2. IV access;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion;
5. Standard tubing, syringes and supplies; and
6. Preparation of chemotherapy agent(s).
Payment for the above is included in the payment for the chemotherapy administration
service.
If a significant separately identifiable evaluation and management service is performed,
the appropriate E & M code should be reported utilizing modifier 25 in addition to the
chemotherapy code. For an evaluation and management service provided on the same
day, a different diagnosis is not required.
E. Coding Rules for Chemotherapy Administration and Nonchemotherapy
Injections and Infusion Services
Instruct physicians to follow the CPT coding instructions to report chemotherapy
administration and nonchemotherapy injections and infusion services with the exception
listed in subsection C for CPT code 90772. The physician should be aware of the
following specific rules.
When administering multiple infusions, injections or combinations, the physician should
report only one “initial” service code unless protocol requires that two separate IV sites
must be used. The initial code is the code that best describes the key or primary reason
for the encounter and should always be reported irrespective of the order in which the
infusions or injections occur. If an injection or infusion is of a subsequent or concurrent
nature, even if it is the first such service within that group of services, then a subsequent
or concurrent code should be reported. For example, the first IV push given subsequent
to an initial one-hour infusion is reported using a subsequent IV push code.
If more than one “initial” service code is billed per day, the A/B MAC (B) shall deny the
second initial service code unless the patient has to come back for a separately
identifiable service on the same day or has two IV lines per protocol. For these
separately identifiable services, instruct the physician to report with modifier 59.
The CPT includes a code for a concurrent infusion in addition to an intravenous infusion
for therapy, prophylaxis or diagnosis. Allow only one concurrent infusion per patient per
encounter. Do not allow payment for the concurrent infusion billed with modifier 59
unless it is provided during a second encounter on the same day with the patient and is
documented in the medical record.
For chemotherapy administration and therapeutic, prophylactic and diagnostic injections
and infusions, an intravenous or intra-arterial push is defined as: 1.) an injection in
which the healthcare professional is continuously present to administer the
substance/drug and observe the patient; or 2.) an infusion of 15 minutes or less.
The physician may report the infusion code for “each additional hour” only if the infusion
interval is greater than 30 minutes beyond the 1 hour increment. For example if the
patient receives an infusion of a single drug that lasts 1 hour and 45 minutes, the
physician would report the “initial” code up to 1 hour and the add-on code for the
additional 45 minutes.
Several chemotherapy administration and nonchemotherapy injection and infusion
service codes have the following parenthetical descriptor included as a part of the CPT
code, “List separately in addition to code for primary procedure.” Each of these codes
has a physician fee schedule indicator of “ZZZ” meaning this service is allowed if billed
with another chemotherapy administration or nonchemotherapy injection and infusion
service code.
Do not interpret this parenthetical descriptor to mean that the add-on code can be billed
only if it is listed with another drug administration primary code. For example, code
90761 will be ordinarily billed with code 90760. However, there may be instances when
only the add-on code, 90761, is billed because an “initial” code from another section in
the drug administration codes, instead of 90760, is billed as the primary code.
Pay for code 96523, “Irrigation of implanted venous access device for drug delivery
systems,” if it is the only service provided that day. If there is a visit or other
chemotherapy administration or nonchemotherapy injection or infusion service provided
on the same day, payment for 96523 is included in the payment for the other service.
F. Chemotherapy Administration (or Nonchemotherapy Injection and Infusion) and
Evaluation and Management Services Furnished on the Same Day
For services furnished on or after January 1, 2004, do not allow payment for CPT code
99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion
code or a chemotherapy administration code. Apply this policy to code 99211 when it is
billed with a diagnostic or therapeutic injection code on or after January 1, 2005.
Physicians providing a chemotherapy administration service or a nonchemotherapy drug
infusion service and evaluation and management services, other than CPT code 99211, on
the same day must bill in accordance with §30.6.6 using modifier 25. The A/B MACs
(B) pay for evaluation and management services provided on the same day as the
chemotherapy administration services or a nonchemotherapy injection or infusion
service if the evaluation and management service meets the requirements of section
§30.6.6 even though the underlying codes do not have global periods. If a chemotherapy
service and a significant separately identifiable evaluation and management service are
provided on the same day, a different diagnosis is not required.
In 2005, the Medicare physician fee schedule status database indicators for therapeutic
and diagnostic injections were changed from T to A. Thus, beginning in 2005, the policy
on evaluation and management services, other than 99211, that is applicable to a
chemotherapy or a nonchemotherapy injection or infusion service applies equally to these
codes.
30.6 - Evaluation and Management Service Codes - General (Codes
99201 - 99499)
(Rev. 178, 05-14-04)
B3-15501-15501.1
30.6.1 - Selection of Level of Evaluation and Management Service
(Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)
A. Use of CPT Codes
Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services,
including evaluation and management services. Medicare will pay for E/M services for
specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist
(CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill
these services. A physician assistant (PA) may also provide a physician service,
however, the physician collaboration and general supervision rules as well as all billing
rules apply to all the above non-physician practitioners. The service provided must be
medically necessary and the service must be within the scope of practice for a non-
physician practitioner in the State in which he/she practices. Do not pay for CPT
evaluation and management codes billed by physical therapists in independent practice or
by occupational therapists in independent practice.
Medical necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT code. It would not be medically necessary or
appropriate to bill a higher level of evaluation and management service when a lower
level of service is warranted. The volume of documentation should not be the primary
influence upon which a specific level of service is billed. Documentation should support
the level of service reported. The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate medical record.
B. Selection of Level of Evaluation and Management Service
Instruct physicians to select the code for the service based upon the content of the service.
The duration of the visit is an ancillary factor and does not control the level of the service
to be billed unless more than 50 percent of the face-to-face time (for non-inpatient
services) or more than 50 percent of the floor time (for inpatient services) is spent
providing counseling or coordination of care as described in subsection C.
Any physician or non-physician practitioner (NPP) authorized to bill Medicare services
will be paid by the Medicare Administrative Contractor (MAC) at the appropriate
physician fee schedule amount based on the rendering UPIN/PIN.
"Incident to" Medicare Part B payment policy is applicable for office visits when the
requirements for "incident to" are met (refer to sections 60.1, 60.2, and 60.3, chapter 15
in IOM 100-02).
SPLIT/SHARED E/M SERVICE
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 UPIN/PIN. 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 UPIN/PIN, and payment will be made at the appropriate physician fee
schedule payment.
Hospital Inpatient/Outpatient (On Campus or Off Campus)/Emergency
Department Setting
When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off
campus outpatient hospital) 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 UPIN/PIN number. However, 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 UPIN/PIN. Payment will be made at the appropriate physician
fee schedule rate based on the UPIN/PIN entered on the claim.
EXAMPLES OF SHARED VISITS
1. If the NPP sees a hospital inpatient in the morning and the physician follows with a
later face-to-face visit with the patient on the same day, the physician or the NPP may
report the service.
2. In an office setting the NPP performs a portion of an E/M encounter and the physician
completes the E/M service. If the "incident to" requirements are met, the physician
reports the service. If the “incident to” requirements are not met, the service must be
reported using the NPP’s UPIN/PIN.
In the rare circumstance when a physician (or NPP) provides a service that does not
reflect a CPT code description, the service must be reported as an unlisted service with
CPT code 99499. A description of the service provided must accompany the claim. The
MAC has the discretion to value the service when the service does not meet the full terms
of a CPT code description (e.g., only a history is performed). The MAC also determines
the payment based on the applicable percentage of the physician fee schedule depending
on whether the claim is paid at the physician rate or the non-physician practitioner rate.
CPT modifier -52 (reduced services) must not be used with an evaluation and
management service. Medicare does not recognize modifier -52 for this purpose.
C. Selection of Level of Evaluation and Management Service Based On Duration of
Coordination of Care and/or Counseling
Advise physicians that when counseling and/or coordination of care dominates (more
than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case
of inpatient services), time is the key or controlling factor in selecting the level of service.
In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria
applicable to the type/level of service provided. However, the physician may document
time spent with the patient in conjunction with the medical decision-making involved and
a description of the coordination of care or counseling provided. Documentation must be
in sufficient detail to support the claim.
EXAMPLE: A cancer patient has had all preliminary studies completed and a medical
decision to implement chemotherapy. At an office visit the physician discusses the
treatment options and subsequent lifestyle effects of treatment the patient may encounter
or is experiencing. The physician need not complete a history and physical examination
in order to select the level of service. The time spent in counseling/coordination of care
and medical decision-making will determine the level of service billed.
The code selection is based on the total time of the face-to-face encounter or floor time,
not just the counseling time. The medical record must be documented in sufficient detail
to justify the selection of the specific code if time is the basis for selection of the code.
In the office and other outpatient setting, counseling and/or coordination of care must be
provided in the presence of the patient if the time spent providing those services is used
to determine the level of service reported. Face-to-face time refers to the time with the
physician only. Counseling by other staff is not considered to be part of the face-to-face
physician/patient encounter time. Therefore, the time spent by the other staff is not
considered in selecting the appropriate level of service. The code used depends upon the
physician service provided.
In an inpatient setting, the counseling and/or coordination of care must be provided at the
bedside or on the patient’s hospital floor or unit that is associated with an individual
patient. Time spent counseling the patient or coordinating the patient’s care after the
patient has left the office or the physician has left the patient’s floor or begun to care for
another patient on the floor is not considered when selecting the level of service to be
reported.
The duration of counseling or coordination of care that is provided face-to-face or on the
floor may be estimated but that estimate, along with the total duration of the visit, must
be recorded when time is used for the selection of the level of a service that involves
predominantly coordination of care or counseling.
D. Use of Highest Levels of Evaluation and Management Codes
A/B MACs (B) must advise physicians that to bill the highest levels of visit codes, the
services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient
visit, the history must meet CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a complete past
(medical and surgical) family and social history obtained at that visit. In the case of an
established patient, it is acceptable for a physician to review the existing record and
update it to reflect only changes in the patient’s medical, family, and social history from
the last encounter, but the physician must review the entire history for it to be considered
a comprehensive history.
The comprehensive examination may be a complete single system exam such as cardiac,
respiratory, psychiatric, or a complete multi-system examination.
30.6.1.1 - Initial Preventive Physical Examination (IPPE) and Annual
Wellness Visit (AWV)
(Rev. 3096, Issued: 10-17-14, Effective: 01-27-14, Implementation: 11-18-14)
A. Definitions
1. Initial Preventive Physical Examination (IPPE)
The initial preventive physical examination (IPPE), or “Welcome to Medicare Preventive
Visit” is a preventive visit authorized by sections 1861(s)(2)(w) and 1861(ww) of the
Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), and
411.15(k)(11)).
As described in the implementing regulations, the IPPE includes the following:
(1) review of the individual’s medical and social history with attention to modifiable
risk factors for disease detection,
(2) review of the individual’s potential (risk factors) for depression or other mood
disorders,
(3) review of the individual’s functional ability and level of safety,
(4) an examination to include measurement of the individual’s height, weight, body
mass index, blood pressure, a visual acuity screen, and other factors as deemed
appropriate, based on the beneficiary’s medical and social history,
(5) end-of-life planning, upon agreement of the individual,
(6) education, counseling, and referral, as deemed appropriate, based on the results of
the review and evaluation services described in the previous 5 elements, and
(7) education, counseling, and referral including a brief written plan (e.g., a checklist
or alternative) provided to the individual for obtaining the appropriate screening
and other preventive services, which are separately covered under Medicare Part
B (that is, pneumococcal, influenza and hepatitis B vaccines and their
administration, screening mammography, screening pap smear and screening
pelvic examinations, prostate cancer screening tests, colorectal cancer screening
tests, diabetes outpatient self-management training services, bone mass
measurements, glaucoma screening, medical nutrition therapy for individuals
with diabetes or renal disease, cardiovascular screening blood tests, diabetes
screening tests, screening ultrasound for abdominal aortic aneurysms, an
electrocardiogram, and additional preventive services covered under Medicare
Part B through the Medicare national coverage determinations process).
2. Annual Wellness Visit (AWV)
Effective January 1, 2011, Sections 1861(s)(2)(FF) and 1861(hhh) of the Social Security
Act and implementing regulations at 42 CFR 410.15, authorize an AWV providing
personalized prevention plan services (PPPS). The AWV is a preventive visit available
to eligible beneficiaries, and identified by HCPCS codes G0438 (Annual wellness visit,
including PPPS, first visit) and G0439 (Annual wellness visit, including PPPS,
subsequent visit). Information, including definitions of relevant terms and coverage
requirements for the AWV are included in Pub. 100-02, Medicare Benefit Policy Manual,
chapter 15, section 280.5.
The first AWV providing PPPS (HCPCS G0438) is a ‘one time’ allowed Medicare
benefit and includes the following elements furnished to an eligible beneficiary by a
health professional:
Review (and administration if needed) of a health risk assessment,
• Establishment of the individual’s medical/family history,
• Establishment of a list of current providers and suppliers that are regularly
involved in providing medical care to the individual,
• Measurement of the individual’s height, weight, body mass index (or waist
circumference, if appropriate), blood pressure (BP), and other routine
measurements as deemed appropriate, based on the individual’s medical and
family history,
• Detection of any cognitive impairment that the individual may have,
• Review of an individual’s potential risk factors for depression, including current
or past experiences with depression or other mood disorders, based on the use of
an appropriate screening instrument for persons without a current diagnosis of
depression, which the health professional may select from various available
standardized screening tests designed for this purpose and recognized by national
professional medical organizations,
• Review of the individual’s functional ability and level of safety, based on direct
observation of the individual, or the use of appropriate screening questions or a
screening questionnaire, which the health professional may select from various
available screening questions or standardized questionnaires designed for this
purpose and recognized by national professional medical organizations,
• Establishment of a written screening schedule for the individual, such as a
checklist for the next 5 to 10 years, as appropriate, based on recommendations of
the United States Preventive Services Task Force (USPSTF) and Advisory
Committee of Immunizations Practices (ACIP), and the individual’s health risk
assessment, health status, screening history, and age-appropriate preventive
services covered by Medicare,
• Establishment of a list of risk factors and conditions of which primary, secondary,
or tertiary interventions are recommended or underway for the individual,
including any mental health conditions or any such risk factors or conditions that
have been identified through an IPPE, and a list of treatment options and their
associated risks and benefits,
• Furnishing of personalized health advice to the individual and a referral, as
appropriate, to health education or preventive counseling services or programs
aimed at reducing identified risk factors and improving self-management or
community-based lifestyle interventions to reduce health risks and promote self-
management and wellness, including weight loss, physical activity, smoking
cessation, fall prevention, and nutrition, and,
• Any other element(s) determined appropriate by the Secretary through the
national coverage determinations process.
Subsequent AWVs providing PPPS (HCPCS G0439) include the following key elements
furnished to an eligible beneficiary by a health professional:
Review (and administration, if needed) of an updated health risk assessment,
• Update of the individual’s medical/family history,
• Update to the list of current providers and suppliers that are regularly involved in
providing medical care to the individual as that list was developed for the first
AWV providing PPPS, or the previous subsequent AWV providing PPPS,
• Measurement of an individual’s weight (or waist circumference), blood pressure,
and other routine measurements as deemed appropriate, based on the individual’s
medical and family history,
• Detection of any cognitive impairment that the individual may have,
• Update to the individual’s written screening schedule as developed at the first
AWV providing PPPS,
• Update to the individual’s list of risk factors and conditions for which primary,
secondary, or tertiary interventions are recommended or are underway for the
individual, as that list was developed at the first AWV providing PPPS, or the
previous subsequent AWV providing PPPS,
• Furnishing of personalized health advice to the individual and a referral, as
appropriate, to health education or preventive counseling services or programs,
and,
• Any other element determined appropriate by the Secretary through the national
coverage determinations process.
See chapter 18 of this manual for additional information regarding preventive services
that are separately covered under Medicare Part B.
B. Who May Perform an IPPE or AWV
The A/B MAC (B) pays the appropriate physician fee schedule amount based on the
rendering National Provider Identification (NPI) number.
The IPPE may be performed by:
• a doctor of medicine or osteopathy as defined in Section 1861(r) (1) of the Social
Security Act, or
• a qualified nonphysician practitioner (nurse practitioner, physician assistant or
clinical nurse specialist).
The AWV may be performed by a health professional, which is defined as:
• a doctor of medicine or osteopathy as defined in Section 1861(r)(1) of the Social
Security Act,
a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in
section 1861(aa)(5) of the Social Security Act), or
• a medical professional (including a health educator, registered dietitian, nutrition
professional, or other licensed practitioner) or a team of such medical
professionals, working under the direct supervision of a physician (doctor of
medicine or osteopathy).
C. Eligibility
1. IPPE
Medicare pays for one IPPE per beneficiary per lifetime for beneficiaries within the first
12 months of the effective date of the beneficiary’s first Part B coverage period.
2. AWV
Medicare pays for an AWV for a beneficiary who is no longer within 12 months after the
effective date of his/her first Medicare Part B coverage period, and who has not received
either an IPPE or an AWV providing PPPS within the past 12 months. Medicare pays for
only one first AWV (HCPCS G0438), per beneficiary per lifetime. All subsequent
AWVs must be billed using HCPCS G0439.
D. Deductible and Coinsurance
1. IPPE
The Medicare deductible and coinsurance apply for the IPPE provided before January 1,
2009.
The Medicare deductible is waived effective for the IPPE provided on or after January 1,
2009. However, the applicable coinsurance continues to apply for the IPPE provided on
or after January 1, 2009.
As a result of the Affordable Care Act (ACA), effective for the IPPE provided on or after
January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only)
are waived.
2. AWV
As a result of the ACA, effective January 1, 2011, the Medicare deductible and
coinsurance for the AWV (HCPCS G0438 and G0439) are waived.
E. The EKG Component of the IPPE
The once-in-a-lifetime screening EKG may be performed, as appropriate, with a referral
from an IPPE.
F. HCPCS Codes Used to Bill the IPPE or AWV
1. HCPCS Codes Used to Bill the IPPE
For IPPE and EKG services provided prior to January 1, 2009, the physician or qualified
NPP shall bill HCPCS code G0344 for the IPPE performed face-to-face, and HCPCS
code G0366 for performing a screening EKG that includes both the interpretation and
report. If the primary physician or qualified NPP performs only the IPPE, he/she shall
bill HCPCS code G0344 only. The physician or entity that performs the screening EKG
that includes both the interpretation and report shall bill HCPCS code G0366. The
physician or entity that performs the screening EKG tracing only (without interpretation
and report) shall bill HCPCS code G0367. The physician or entity that performs the
interpretation and report only (without the EKG tracing) shall bill HCPCS code G0368.
Medicare will pay for a screening EKG only as part of the IPPE. HCPCS codes G0344,
G0366, G0367 and G0368 will not be billable codes effective on or after January 1, 2009.
Effective for a beneficiary who has the IPPE on or after January 1, 2009, and within
his/her 12-month enrollment period of Medicare Part B, the IPPE and screening EKG
services are billable with the appropriate HCPCS G code(s).
The physician or qualified NPP shall bill HCPCS code G0402 for the IPPE performed
face-to-face with the patient.
The physician or entity shall bill HCPCS code G0403 for performing the complete
screening EKG that includes the tracing, interpretation and report.
The physician or entity that performs the screening EKG tracing only (without
interpretation and report) shall bill HCPCS code G0404.
The physician or entity that performs the screening EKG interpretation and report only,
(without the EKG tracing) shall bill HCPCS code G0405.
2. HCPCS Codes Used to Bill the AWV
For the first AWV provided on or after January 1, 2011, the health professional shall bill
HCPCS G0438 (Annual wellness visit, including PPPS, first visit). This is a once per
beneficiary per lifetime allowable Medicare Part B benefit.
All subsequent AWVs shall be billed with HCPCS G0439 (Annual Wellness Visit,
including PPPS, subsequent visit). In the event that a beneficiary selects a new health
professional to complete a subsequent AWV, the new health professional will continue to
bill the subsequent AWV with HCPCS G0439.
NOTE: For an IPPE or AWV performed during the global period of surgery, refer to
chapter 12, §30.6.6 of this chapter for reporting instructions.
G. Documentation for the IPPE or AWV
Practitioners eligible to furnish an IPPE or an AWV are required to use the 1995 and
1997 E/M documentation guidelines to document the medical record with the appropriate
clinical information.
(http://xmarks.com/site/www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp). All
referrals and a written medical plan must be included in this documentation.
H. Reporting a Medically Necessary E/M Service Furnished During the Same
Encounter as an IPPE or AWV
When the physician or qualified NPP, or for AWV the health professional, provides a
significant, separately identifiable medically necessary E/M service in addition to the
IPPE or an AWV, CPT codes 99201 - 99215 may be reported depending on the clinical
appropriateness of the circumstances. CPT Modifier -25 shall be appended to the
medically necessary E/M service identifying this service as a significant, separately
identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or
G0402, whichever applies based on the date the IPPE is performed, or HCPCS code
G0438 or G0439 whichever AWV code applies).
NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of
history or physical exam portion) may have been part of the IPPE or AWV and should
not be included when determining the most appropriate level of E/M service to be billed
for the medically necessary, separately identifiable, E/M service.
30.6.2 - Billing for Medically Necessary Visit on Same Occasion as
Preventive Medicine Service
(Rev. 1, 10-01-03)
See Chapter 18 for payment for covered preventive services.
When a physician furnishes a Medicare beneficiary a covered visit at the same place and
on the same occasion as a noncovered preventive medicine service (CPT codes 99381-
99397), consider the covered visit to be provided in lieu of a part of the preventive
medicine service of equal value to the visit. A preventive medicine service (CPT codes
99381-99397) is a noncovered service. The physician may charge the beneficiary, as a
charge for the noncovered remainder of the service, the amount by which the physician’s
current established charge for the preventive medicine service exceeds his/her current
established charge for the covered visit. Pay for the covered visit based on the lesser of
the fee schedule amount or the physician’s actual charge for the visit. The physician is
not required to give the beneficiary written advance notice of noncoverage of the part of
the visit that constitutes a routine preventive visit. However, the physician is responsible
for notifying the patient in advance of his/her liability for the charges for services that are
not medically necessary to treat the illness or injury.
There could be covered and noncovered procedures performed during this encounter
(e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those
procedures which are for screening for asymptomatic conditions are considered
noncovered and, therefore, no payment is made. Those procedures ordered to diagnose
or monitor a symptom, medical condition, or treatment are evaluated for medical
necessity and, if covered, are paid.
30.6.3 - Payment for Immunosuppressive Therapy Management
(Rev. 1, 10-01-03)
B3-4820-4824
Physicians bill for management of immunosuppressive therapy using the office or
subsequent hospital visit codes that describe the services furnished. If the physician who
is managing the immunotherapy is also the transplant surgeon, he or she bills these visits
with modifier “-24” indicating that the visit during the global period is not related to the
original procedure if the physician also performed the transplant surgery and submits
documentation that shows that the visit is for immunosuppressive therapy.
30.6.4 - Evaluation and Management (E/M) Services Furnished Incident
to Physician’s Service by Nonphysician Practitioners
(Rev. 1, 10-01-03)
When evaluation and management services are furnished incident to a physician’s service
by a nonphysician practitioner, the physician may bill the CPT code that describes the
evaluation and management service furnished.
When evaluation and management services are furnished incident to a physician’s service
by a nonphysician employee of the physician, not as part of a physician service, the
physician bills code 99211 for the service.
A physician is not precluded from billing under the “incident to” provision for services
provided by employees whose services cannot be paid for directly under the Medicare
program. Employees of the physician may provide services incident to the physician’s
service, but the physician alone is permitted to bill Medicare.
Services provided by employees as “incident to” are covered when they meet all the
requirements for incident to and are medically necessary for the individual needs of the
patient.
30.6.5 - Physicians in Group Practice
(Rev. 1, 10-01-03)
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.
Physicians in the same group practice but who are in different specialties may bill and be
paid without regard to their membership in the same group.
30.6.6 - Payment for Evaluation and Management Services Provided
During Global Period of Surgery
(Rev. 954, Issued: 05-19-06, Effective: 06-01-06, Implementation: 08-20-06)
A. CPT Modifier “-24” - Unrelated Evaluation and Management Service by Same
Physician During Postoperative Period
A/B MACs (B) pay for an evaluation and management service other than inpatient
hospital care before discharge from the hospital following surgery (CPT codes 99221-
99238) if it was provided during the postoperative period of a surgical procedure,
furnished by the same physician who performed the procedure, billed with CPT modifier
“-24,” and accompanied by documentation that supports that the service is not related to
the postoperative care of the procedure. They do not pay for inpatient hospital care that
is furnished during the hospital stay in which the surgery occurred unless the doctor is
also treating another medical condition that is unrelated to the surgery. All care provided
during the inpatient stay in which the surgery occurred is compensated through the global
surgical payment.
B. CPT Modifier “-25” - Significant Evaluation and Management Service by Same
Physician on Date of Global Procedure
Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only
be used on claims for evaluation and management (E/M) services, and only when these
services are provided by the same physician (or same qualified nonphysician practitioner)
to the same patient on the same day as another procedure or other service. A/B MACs
(B) pay for an E/M service provided on the day of a procedure with a global fee period if
the physician indicates that the service is for a significant, separately identifiable E/M
service that is above and beyond the usual pre- and post-operative work of the procedure.
Different diagnoses are not required for reporting the E/M service on the same date as the
procedure or other service. Modifier -25 is added to the E/M code on the claim.
Both the medically necessary E/M service and the procedure must be appropriately and
sufficiently documented by the physician or qualified nonphysician practitioner in the
patient’s medical record to support the claim for these services, even though the
documentation is not required to be submitted with the claim.
If the physician bills the service with the CPT modifier “-25,” A/B MACs (B) pay for the
service in addition to the global fee without any other requirement for documentation
unless one of the following conditions is met:
• When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and
93937), the physician must document that the service was unrelated to the
dialysis and could not be performed during the dialysis procedure;
• When preoperative critical care codes are being billed on the date of the
procedure, the diagnosis must support that the service is unrelated to the
performance of the procedure; or
• When an A/B MAC (B) has conducted a specific medical review process and
determined, after reviewing the data, that an individual or a group has high use of
modifier “-25” compared to other physicians, has done a case-by-case review of
the records to verify that the use of modifier was inappropriate, and has educated
the individual or group, the A/B MAC (B) may impose prepayment screens or
documentation requirements for that provider or group. When a A/B MAC (B)
has completed a review and determined that a high usage rate of modifier “-57,”
the A/B MAC (B) must complete a case-by-case review of the records. Based
upon this review, the A/B MAC (B) will educate providers regarding the
appropriate use of modifier “-57.” If high usage rates continue, the A/B MAC
(B) may impose prepayment screens or documentation requirements for that
provider or group.
A/B MACs (B) may not permit the use of CPT modifier “-25” to generate payment for
multiple evaluation and management services on the same day by the same physician,
notwithstanding the CPT definition of the modifier.
C. CPT Modifier “-57” - Decision for Surgery Made Within Global Surgical Period
A/B MACs (B) pay for an evaluation and management service on the day of or on the
day before a procedure with a 90-day global surgical period if the physician uses CPT
modifier “-57” to indicate that the service resulted in the decision to perform the
procedure. A/B MACs (B) may not pay for an evaluation and management service billed
with the CPT modifier “-57” if it was provided on the day of or the day before a
procedure with a 0 or 10-day global surgical period.
30.6.7 - Payment for Office or Other Outpatient Evaluation and
Management (E/M) Visits (Codes 99201 - 99215)
(Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)
A. Definition of New Patient for Selection of E/M Visit Code
Interpret 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.
B. Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems
As for all other E/M services except where specifically noted, the Medicare
Administrative Contractors (MACs) may not pay two E/M office visits billed by a
physician (or physician of the same specialty from the same group practice) for the same
beneficiary on the same day unless the physician documents that the visits were for
unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient
hospital setting which could not be provided during the same encounter (e.g., office visit
for blood pressure medication evaluation, followed five hours later by a visit for
evaluation of leg pain following an accident).
C. Office/Outpatient or Emergency Department E/M Visit on Day of Admission to
Nursing Facility
MACs may not pay a physician for an emergency department visit or an office visit and a
comprehensive nursing facility assessment on the same day. Bundle E/M visits on the
same date provided in sites other than the nursing facility into the initial nursing facility
care code when performed on the same date as the nursing facility admission by the same
physician.
D. Drug Administration Services and E/M Visits Billed on Same Day of Service
MACs must advise physicians that CPT code 99211 cannot be paid if it is billed with a
drug administration service such as a chemotherapy or nonchemotherapy drug infusion
code (effective January 1, 2004). This drug administration policy was expanded in the
Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or
diagnostic injection code (effective January 1, 2005). Therefore, when a medically
necessary, significant and separately identifiable E/M service (which meets a higher
complexity level than CPT code 99211) is performed, in addition to one of these drug
administration services, the appropriate E/M CPT code should be reported with modifier
-25. Documentation should support the level of E/M service billed. For an E/M service
provided on the same day, a different diagnosis is not required.
30.6.8 - Payment for Hospital Observation Services and Observation or
Inpatient Care Services (Including Admission and Discharge Services)
(Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
A. Who May Bill Observation Care Codes
Observation care is a well-defined set of specific, clinically appropriate services, which
include ongoing short term treatment, assessment, and reassessment, that are furnished
while a decision is being made regarding whether patients will require further treatment
as hospital inpatients or if they are able to be discharged from the hospital. Observation
services are commonly ordered for patients who present to the emergency department and
who then require a significant period of treatment or monitoring in order to make a
decision concerning their admission or discharge.
In only rare and exceptional cases do reasonable and necessary outpatient observation
services span more than 48 hours. In the majority of cases, the decision whether to
discharge a patient from the hospital following resolution of the reason for the
observation care or to admit the patient as an inpatient can be made in less than 48 hours,
usually in less than 24 hours.
A/B MACs (B) pay for initial observation care billed by only the physician who ordered
hospital outpatient observation services and was responsible for the patient during his/her
observation care. A physician who does not have inpatient admitting privileges but who
is authorized to furnish hospital outpatient observation services may bill these codes.
For a physician to bill 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.
Payment for an initial observation care code is for all the care rendered by the ordering
physician on the date the patient’s observation services began. All other physicians who
furnish consultations or additional evaluations or services while the patient is receiving
hospital outpatient observation services must bill the appropriate outpatient service codes.
For example, if an internist orders observation services and asks another physician to
additionally evaluate the patient, only the internist may bill the initial and subsequent
observation care codes. The other physician who evaluates the patient must bill the new
or established office or other outpatient visit codes as appropriate.
For information regarding hospital billing of observation services, see Chapter 4, §290.
B. Physician Billing for Observation Care Following Initiation of Observation
Services
Similar to initial observation codes, payment for a subsequent observation care code is
for all the care rendered by the treating physician on the day(s) other than the initial or
discharge date. All other physicians who furnish consultations or additional evaluations
or services while the patient is receiving hospital outpatient observation services must bill
the appropriate outpatient service codes.
When a patient receives observation care for less than 8 hours on the same calendar date,
the Initial Observation Care, from CPT code range 99218 - 99220, shall be reported by
the physician. The Observation Care Discharge Service, CPT code 99217, shall not be
reported for this scenario.
When a patient is admitted for observation care and then is discharged on a different
calendar date, the physician shall report Initial Observation Care, from CPT code range
99218 - 99220, and CPT observation care discharge CPT code 99217. On the rare
occasion when a patient remains in observation care for 3 days, the physician shall report
an initial observation care code (99218-99220) for the first day of observation care, a
subsequent observation care code (99224-99226) for the second day of observation care,
and an observation care discharge CPT code 99217 for the observation care on the
discharge date. When observation care continues beyond 3 days, the physician shall
report a subsequent observation care code (99224-99226) for each day between the first
day of observation care and the discharge date.
When a patient receives observation care for a minimum of 8 hours, but less than 24
hours, and is discharged on the same calendar date, Observation or Inpatient Care
Services (Including Admission and Discharge Services) from CPT code range 99234 -
99236 shall be reported. The observation discharge, CPT code 99217, cannot also be
reported for this scenario.
C. Documentation Requirements for Billing Observation or Inpatient Care Services
(Including Admission and Discharge Services)
The physician shall satisfy the E/M documentation guidelines for furnishing observation
care or inpatient hospital care. In addition to meeting the documentation requirements for
history, examination, and medical decision making, documentation in the medical record
shall include:
• Documentation stating the stay for observation care or inpatient hospital care
involves 8 hours, but less than 24 hours;
• Documentation identifying the billing physician was present and personally
performed the services; and
• Documentation identifying the order for observation services, progress notes, and
discharge notes were written by the billing physician.
In the rare circumstance when a patient receives observation services for more than 2
calendar dates, the physician shall bill observation services furnished on day(s) other than
the initial or discharge date using subsequent observation care codes. The physician may
not use the subsequent hospital care codes since the patient is not an inpatient of the
hospital.
D. Admission to Inpatient Status Following Observation Care
If the same physician who ordered hospital outpatient observation services also admits
the patient to inpatient status before the end of the date on which the patient began
receiving hospital outpatient observation services, pay only an initial hospital visit for the
evaluation and management services provided on that date. Medicare payment for the
initial hospital visit includes all services provided to the patient on the date of admission
by that physician, regardless of the site of service. The physician may not bill an initial
or subsequent observation care code for services on the date that he or she admits the
patient to inpatient status. If the patient is admitted to inpatient status from hospital
outpatient observation care subsequent to the date of initiation of observation services,
the physician must bill an initial hospital visit for the services provided on that date. The
physician may not bill the hospital observation discharge management code (code 99217)
or an outpatient/office visit for the care provided while the patient received hospital
outpatient observation services on the date of admission to inpatient status.
E. Hospital Observation Services During Global Surgical Period
The global surgical fee includes payment for hospital observation (codes 99217, 99218,
99219, 99220, 99224, 99225, 99226, 99234, 99235, and 99236) services unless the
criteria for use of CPT modifiers “-24,” “-25,” or “-57” are met. A/B MACs (B) must
pay for these services in addition to the global surgical fee only if both of the following
requirements are met:
• The hospital observation service meets the criteria needed to justify billing it with
CPT modifiers “-24,” “-25,” or “-57” (decision for major surgery); and
• The hospital observation service furnished by the surgeon meets all of the criteria
for the hospital observation code billed.
Examples of the decision for surgery during a hospital observation period are:
• An emergency department physician orders hospital outpatient observation
services for a patient with a head injury. A neurosurgeon is called in to evaluate
the need for surgery while the patient is receiving observation services and
decides that the patient requires surgery. The surgeon would bill a new or
established office or other outpatient visit code as appropriate with the “-57”
modifier to indicate that the decision for surgery was made during the evaluation.
The surgeon must bill the office or other outpatient visit code because the patient
receiving hospital outpatient observation services is not an inpatient of the
hospital. Only the physician who ordered hospital outpatient observation services
may bill for observation care.
• A neurosurgeon orders hospital outpatient observation services for a patient with
a head injury. During the observation period, the surgeon makes the decision for
surgery. The surgeon would bill the appropriate level of hospital observation
code with the “-57” modifier to indicate that the decision for surgery was made
while the surgeon was providing hospital observation care.
Examples of hospital observation services during the postoperative period of a surgery
are:
• A surgeon orders hospital outpatient observation services for a patient with
abdominal pain from a kidney stone on the 80th day following a TURP
(performed by that surgeon). The surgeon decides that the patient does not
require surgery. The surgeon would bill the observation code with CPT modifier
“-24” and documentation to support that the observation services are unrelated to
the surgery.
• A surgeon orders hospital outpatient observation services for a patient with
abdominal pain on the 80th day following a TURP (performed by that surgeon).
While the patient is receiving hospital outpatient observation services, the surgeon
decides that the patient requires kidney surgery. The surgeon would bill the
observation code with HCPCS modifier “-57” to indicate that the decision for
surgery was made while the patient was receiving hospital outpatient observation
services. The subsequent surgical procedure would be reported with modifier “-
79.”
• A surgeon orders hospital outpatient observation services for a patient with
abdominal pain on the 20th day following a resection of the colon (performed by
that surgeon). The surgeon determines that the patient requires no further colon
surgery and discharges the patient. The surgeon may not bill for the observation
services furnished during the global period because they were related to the
previous surgery.
An example of a billable hospital observation service on the same day as a procedure is
when a physician repairs a laceration of the scalp in the emergency department for a
patient with a head injury and then subsequently orders hospital outpatient observation
services for that patient. The physician would bill the observation code with a CPT
modifier 25 and the procedure code.
30.6.9 - Payment for Inpatient Hospital Visits - General
(Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
A. Hospital Visit and Critical Care on Same Day
When a hospital inpatient or office/outpatient evaluation and management service (E/M)
are furnished on a calendar date at which time the patient does not require critical care
and the patient subsequently requires critical care both the critical Care Services (CPT
codes 99291 and 99292) and the previous E/M service may be paid on the same date of
service. Hospital emergency department services are not paid for the same date as
critical care services when provided by the same physician to the same patient.
During critical care management of a patient those services that do not meet the level of
critical care shall be reported using an inpatient hospital care service with CPT
Subsequent Hospital Care using a code from CPT code range 99231 - 99233.
Both Initial Hospital Care (CPT codes 99221 - 99223) and 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 and qualified nonphysician practitioners (NPPs) are advised to retain
documentation for discretionary A/B MAC (B) review should claims be questioned for
both hospital care and critical care claims. The retained documentation shall support
claims for critical care when the same physician or physicians of the same specialty in a
group practice report critical care services for the same patient on the same calendar date
as other E/M services.
B. Two Hospital Visits Same Day
A/B MACs (B) pay a physician for only one hospital visit per day for the same patient,
whether the problems seen during the encounters are related or not. The inpatient
hospital visit descriptors contain the phrase “per day” which means that the code and the
payment established for the code represent all services provided on that date. The
physician should select a code that reflects all services provided during the date of the
service.
C. Hospital Visits Same Day But by Different Physicians
In a hospital inpatient situation involving one physician covering for another, if physician
A sees the patient in the morning and physician B, who is covering for A, sees the same
patient in the evening, A/B MACs (B) do not pay physician B for the second visit. The
hospital visit descriptors include the phrase “per day” meaning care for the day.
If the physicians are each responsible for a different aspect of the patient’s care, pay both
visits if the physicians are in different specialties and the visits are billed with different
diagnoses. There are circumstances where concurrent care may be billed by physicians
of the same specialty.
D. Visits to Patients in Swing Beds
If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital
care codes apply. If the inpatient care is being billed by the hospital as nursing facility
care, then the nursing facility codes apply.
30.6.9.1 - Payment for Initial Hospital Care Services and Observation or
Inpatient Care Services (Including Admission and Discharge Services)
(Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
A. Initial Hospital Care From Emergency Room
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.
B. Initial Hospital Care on Day Following Visit
A/B MACs (B) pay 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.
C. Initial Hospital Care and Discharge on Same Day
When the patient is admitted to inpatient hospital care for less than 8 hours on the same
date, then Initial Hospital Care, from CPT code range 99221 - 99223, shall be reported by
the physician. The Hospital Discharge Day Management service, CPT codes 99238 or
99239, shall not be reported for this scenario.
When a patient is admitted to inpatient initial hospital care and then discharged on a
different calendar date, the physician shall report an Initial Hospital Care from CPT code
range 99221 - 99223 and a Hospital Discharge Day Management service, CPT code
99238 or 99239.
When a patient has been admitted to inpatient hospital care for a minimum of 8 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 CPT code
range 99234 - 99236, shall be reported.
D. Documentation Requirements for Billing Observation or Inpatient Care Services
(Including Admission and Discharge Services)
The physician shall satisfy the E/M documentation guidelines for admission to and
discharge from inpatient observation or hospital care. In addition to meeting the
documentation requirements for history, examination and medical decision making
documentation in the medical record shall include:
• Documentation stating the stay for hospital treatment or observation care
status involves 8 hours but less than 24 hours;
• Documentation identifying the billing physician was present and personally
performed the services; and
• Documentation identifying the admission and discharge notes were written by
the billing physician.
E. Physician Services Involving Transfer From One Hospital to Another; Transfer
Within Facility to Prospective Payment System (PPS) Exempt Unit of Hospital;
Transfer From One Facility to Another Separate Entity Under Same Ownership
and/or Part of Same Complex; or Transfer From One Department to Another
Within Single Facility
Physicians may bill both the hospital discharge management code and an initial hospital
care code when the discharge and admission do not occur on the same day if the transfer
is between:
• Different hospitals;
• Different facilities under common ownership which do not have merged
records; or
• Between the acute care hospital and a PPS exempt unit within the same
hospital when there are no merged records.
In all other transfer circumstances, the physician should bill only the appropriate level of
subsequent hospital care for the date of transfer.
F. Initial Hospital Care Service History and Physical That Is Less Than
Comprehensive
When a physician performs a visit that meets the definition of a Level 5 office visit
several days prior to an admission and on the day of admission performs less than a
comprehensive history and physical, he or she should report the office visit that reflects
the services furnished and also report the lowest level initial hospital care code (i.e., code
99221) for the initial hospital admission. A/B MACs (B) pay the office visit as billed and
the Level 1 initial hospital care code.
Physicians who provide an initial visit to a patient during inpatient hospital care that
meets the minimum key component work and/or medical necessity requirements shall
report an initial hospital care code (99221-99223). The principal physician of record shall
append modifier “-AI” (Principal Physician of Record) to the claim for the initial hospital
care code. This modifier will identify the physician who oversees the patient’s care from
all other physicians who may be furnishing specialty care.
Physicians may bill initial hospital care service codes (99221-99223), for services that
were reported with CPT consultation codes (99241 - 99255) prior to January 1, 2010,
when the furnished service and documentation meet the minimum key component work
and/or medical necessity requirements. Physicians must meet all the requirements of the
initial hospital care codes, including “a detailed or comprehensive history” and “a
detailed or comprehensive examination” to report CPT code 99221, which are greater
than the requirements for consultation codes 99251 and 99252.
Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem
focused interval history” and “an expanded problem focused interval history.” An E/M
service that could be described by CPT consultation code 99251 or 99252 could
potentially meet the component work and medical necessity requirements to report 99231
or 99232. Physicians may report a subsequent hospital care CPT code for services that
were reported as CPT consultation codes (99241 - 99255) prior to January 1, 2010, where
the medical record appropriately demonstrates that the work and medical necessity
requirements are met for reporting a subsequent hospital care code (under the level
selected), even though the reported code is for the provider's first E/M service to the
inpatient during the hospital stay.
Reporting CPT code 99499 (Unlisted evaluation and management service) should be
limited to cases where there is no other specific E/M code payable by Medicare that
describes that service. Reporting CPT code 99499 requires submission of medical
records and A/B MAC (B) manual medical review of the service prior to payment. A/B
MACs (B) shall expect reporting under these circumstances to be unusual.
G. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are
Involved in Same Admission
In the inpatient hospital setting all physicians (and qualified nonphysician practitioners
where permitted) who perform an initial evaluation may bill the initial hospital care codes
(99221 - 99223) or nursing facility care codes (99304 - 99306). A/B MACs (B) consider
only one M.D. or D.O. to be the principal physician of record (sometimes referred to as
the admitting physician.) The principal physician of record is identified in Medicare as
the physician who oversees the patient’s care from other physicians who may be
furnishing specialty care. Only the principal physician of record shall append modifier “-
AI” (Principal Physician of Record) in addition to the E/M code. Follow-up visits in the
facility setting shall be billed as subsequent hospital care visits and subsequent nursing
facility care visits.
30.6.9.2 - Subsequent Hospital Visit and Hospital Discharge Day
Management (Codes 99231 - 99239)
(Rev. 1460, Issued: 02-22-08, Effective: 04-01-08, Implementation: 04-07-08)
A. Subsequent Hospital Visits During the Global Surgery Period
(Refer to §§40-40.4 on global surgery)
The Medicare physician fee schedule payment amount for surgical procedures includes
all services (e.g., evaluation and management visits) that are part of the global surgery
payment; therefore, A/B MACs (B) shall not pay more than that amount when a bill is
fragmented for staged procedures.
B. Hospital Discharge Day Management Service
Hospital Discharge Day Management Services, CPT code 99238 or 99239 is a face-to-
face evaluation and management (E/M) service between the attending physician 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 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 physician of record reports the discharge day management service.
Physicians or qualified nonphysician practitioners, other than the attending physician,
who have been managing concurrent health care problems not primarily managed by the
attending physician, and who are not acting on behalf of the attending physician, shall use
Subsequent Hospital Care (CPT code range 99231 - 99233) for a final visit.
Medicare pays for the paperwork of patient discharge day management through the pre-
and post- service work of an E/M service.
C. Subsequent Hospital Visit and Discharge Management on Same Day
Pay only the hospital discharge management code on the day of discharge (unless it is
also the day of admission, in which case, refer to §30.6.9.1 C for the policy on
Observation or Inpatient Care Services (Including Admission and Discharge Services
CPT Codes 99234 - 99236). A/B MACs (B) do not pay both a subsequent hospital visit
in addition to hospital discharge day management service on the same day by the same
physician. Instruct physicians that they may not bill for both a hospital visit and hospital
discharge management for the same date of service.
D. Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing
Facility Admission Code When Patient Is Discharged From Hospital and Admitted
to Nursing Facility on Same Day
A/B MACs (B) pay the hospital discharge code (codes 99238 or 99239) in addition to a
nursing facility admission code when they are billed by the same physician with the same
date of service.
If a surgeon is admitting the patient to the nursing facility due to a condition that is not as
a result of the surgery during the postoperative period of a service with the global
surgical period, he/she bills for the nursing facility admission and care with a modifier
“-24” and provides documentation that the service is unrelated to the surgery (e.g., return
of an elderly patient to the nursing facility in which he/she has resided for five years
following discharge from the hospital for cholecystectomy).
A/B MACs (B) do not pay for a nursing facility admission by a surgeon in the
postoperative period of a procedure with a global surgical period if the patient’s
admission to the nursing facility is to receive post operative care related to the surgery
(e.g., admission to a nursing facility to receive physical therapy following a hip
replacement). Payment for the nursing facility admission and subsequent nursing facility
services are included in the global fee and cannot be paid separately.
E. Hospital Discharge Management and Death Pronouncement
Only the physician who personally performs the pronouncement of death shall bill for the
face-to-face Hospital Discharge Day Management Service, CPT code 99238 or 99239.
The date of the pronouncement shall reflect the calendar date of service on the day it was
performed even if the paperwork is delayed to a subsequent date.
30.6.10 - Consultation Services
(Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
Consultation Services versus Other Evaluation and Management (E/M) Visits
Effective January 1, 2010, the consultation codes are no longer recognized for Medicare
Part B payment. Physicians shall code patient evaluation and management visits with
E/M codes that represent where the visit occurs and that identify the complexity of the
visit performed.
In the inpatient hospital setting and the nursing facility setting, physicians (and qualified
nonphysician practitioners where permitted) may bill the most appropriate initial
hospital care code (99221-99223), subsequent hospital care code (99231 and 99232),
initial nursing facility care code (99304-99306), or subsequent nursing facility care
code (99307-99310) that reflects the services the physician or practitioner furnished.
Subsequent hospital care codes could potentially meet the component work and medical
necessity requirements to be reported for an E/M service that could be described by CPT
consultation code 99251 or 99252. A/B MACs (B) shall not find fault in cases where the
medical record appropriately demonstrates that the work and medical necessity
requirements are met for reporting a subsequent hospital care code (under the level
selected), even though the reported code is for the provider's first E/M service to the
inpatient during the hospital stay. Unlisted evaluation and management service (code
99499) shall only be reported for consultation services when an E/M service that could be
described by codes 99251 or 99252 is furnished, and there is no other specific E/M code
payable by Medicare that describes that service. Reporting code 99499 requires
submission of medical records and A/B MAC (B) manual medical review of the service
prior to payment. CMS expects reporting under these circumstances to be unusual. The
principal physician of record is identified in Medicare as the physician who oversees the
patient’s care from other physicians who may be furnishing specialty care. The principal
physician of record shall append modifier “-AI” (Principal Physician of Record), in
addition to the E/M code. Follow-up visits in the facility setting shall be billed as
subsequent hospital care visits and subsequent nursing facility care visits.
In the CAH setting, those CAHs that use method II shall bill the appropriate new or
established visit code for those physician and non-physician practitioners who have
reassigned their billing rights, depending on the relationship status between the physician
and patient.
In the office or other outpatient setting where an evaluation is performed, physicians and
qualified nonphysician practitioners shall use the CPT codes (99201 - 99215) depending
on the complexity of the visit and whether the patient is a new or established patient to
that physician. All physicians and qualified nonphysician practitioners shall follow the
E/M documentation guidelines for all E/M services. These rules are applicable for
Medicare secondary payer claims as well as for claims in which Medicare is the primary
payer.
30.6.11 - Emergency Department Visits (Codes 99281 - 99288)
(Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10)
A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency
Department
Any physician seeing a patient registered in the emergency department may use
emergency department visit codes (for services matching the code description). It is not
required that the physician be assigned to the emergency department.
B. Use of Emergency Department Codes In Office
Emergency department coding is not appropriate if the site of service is an office or
outpatient setting or any sight of service other than an emergency department. The
emergency department codes should only be used if the patient is seen in the emergency
department and the services described by the HCPCS code definition are provided. The
emergency department is defined as an organized hospital-based facility for the provision
of unscheduled or episodic services to patients who present for immediate medical
attention.
C. Use of Emergency Department Codes to Bill Nonemergency Services
Services in the emergency department may not be emergencies. However the codes
(99281 - 99288) are payable if the described services are provided.
However, if the physician asks the patient to meet him or her in the emergency
department as an alternative to the physician’s office and the patient is not registered as a
patient in the emergency department, the physician should bill the appropriate
office/outpatient visit codes. Normally a lower level emergency department code would
be reported for a nonemergency condition.
D. Emergency Department or Office/Outpatient Visits on Same Day As Nursing
Facility Admission
Emergency department visit provided on the same day as a comprehensive nursing
facility assessment are not paid. Payment for evaluation and management services on the
same date provided in sites other than the nursing facility are included in the payment for
initial nursing facility care when performed on the same date as the nursing facility
admission.
E. Physician Billing for Emergency Department Services Provided to Patient by
Both Patient’s Personal Physician and Emergency Department Physician
If a physician advises his/her own patient to go to an emergency department (ED) of a
hospital for care and the physician subsequently is asked by the ED physician to come to
the hospital to evaluate the patient and to advise the ED physician as to whether the
patient should be admitted to the hospital or be sent home, the physicians should bill as
follows:
• If the patient is admitted to the hospital by the patient’s personal physician, then
the patient’s regular physician should bill only the appropriate level of the initial
hospital care (codes 99221 - 99223) because all evaluation and management
services provided by that physician in conjunction with that admission are
considered part of the initial hospital care when performed on the same date as the
admission. The ED physician who saw the patient in the emergency department
should bill the appropriate level of the ED codes.
• If the ED physician, based on the advice of the patient’s personal physician who
came to the emergency department to see the patient, sends the patient home, then
the ED physician should bill the appropriate level of emergency department
service. The patient’s personal physician should also bill the level of emergency
department code that describes the service he or she provided in the emergency
department. If the patient’s personal physician does not come to the hospital to
see the patient, but only advises the emergency department physician by
telephone, then the patient’s personal physician may not bill.
F. Emergency Department Physician Requests Another Physician to See the Patient
in Emergency Department or Office/Outpatient Setting
If the emergency department physician requests that another physician evaluate a given
patient, the other physician should bill an emergency department visit code. If the patient
is admitted to the hospital by the second physician performing the evaluation, he or she
should bill an initial hospital care code and not an emergency department visit code.
30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes
99291 - 99292)
(Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-
2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of
ICD-10)
CRITICAL CARE SERVICES (CODES 99291-99292)
A. Use of Critical Care Codes
Pay for services reported with CPT codes 99291 and 99292 when all the criteria for
critical care and critical care services are met. Critical care is defined as the direct
delivery by a physician(s) medical care for a critically ill or critically injured patient. A
critical illness or injury 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.
Critical care involves high complexity decision making to assess, manipulate, and
support vital system functions(s) to treat single or multiple vital organ system failure
and/or to prevent further life threatening deterioration of the patient’s condition.
Examples of vital organ system failure include, but are not limited to: central nervous
system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory
failure. Although critical care typically requires interpretation of multiple physiologic
parameters and/or application of advanced technology(s), critical care may be provided in
life threatening situations when these elements are not present.
Providing medical care to a critically ill, injured, or post-operative patient qualifies as a
critical care service only if both the illness or injury and the treatment being provided
meet the above requirements.
Critical care is usually, but not always, given in a critical care area such as a coronary
care unit, intensive care unit, respiratory care unit, or the emergency department.
However, payment may be made for critical care services provided in any location as
long as the care provided meets the definition of critical care.
Consult the American Medical Association (AMA) CPT Manual for the applicable codes
and guidance for critical care services provided to neonates, infants and children.
B. Critical Care Services and Medical Necessity
Critical care services must be medically necessary and reasonable. Services provided that
do not meet critical care services or services provided for a patient who is not critically ill
or injured in accordance with the above definitions and criteria but who happens to be in
a critical care, intensive care, or other specialized care unit should be reported using
another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 - 99233).
As described in Section A, critical care services encompass both treatment of “vital organ
failure” and “prevention of further life threatening deterioration of the patient’s
condition.” Therefore, although critical care may be delivered in a moment of crisis or
upon being called to the patient’s bedside emergently, this is not a requirement for
providing critical care service. 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).
Chronic Illness and Critical Care:
Examples of patients whose medical condition may not warrant critical care services:
1. Daily management of a patient on chronic ventilator therapy does not meet the
criteria for critical care unless the critical care is separately identifiable from the
chronic long term management of the ventilator dependence.
2. Management of dialysis or care related to dialysis for a patient receiving ESRD
hemodialysis does not meet the criteria for critical care unless the critical care is
separately identifiable from the chronic long term management of the dialysis
dependence (refer to Chapter 8, §160.4). When a separately identifiable condition
(e.g., management of seizures or pericardial tamponade related to renal failure) is
being managed, it may be billed as critical care if critical care requirements are
met. Modifier -25 should be appended to the critical care code when applicable in
this situation.
Examples of patients whose medical condition may warrant critical care services:
1. An 81 year old male patient is admitted to the intensive care unit following
abdominal aortic aneurysm resection. Two days after surgery he requires fluids
and pressors to maintain adequate perfusion and arterial pressures. He remains
ventilator dependent.
2. A 67 year old female patient is 3 days status post mitral valve repair. She
develops petechiae, hypotension and hypoxia requiring respiratory and circulatory
support.
3. A 70 year old admitted for right lower lobe pneumococcal pneumonia with a
history of COPD becomes hypoxic and hypotensive 2 days after admission.
4. A 68 year old admitted for an acute anterior wall myocardial infarction continues
to have symptomatic ventricular tachycardia that is marginally responsive to
antiarrhythmic therapy.
Examples of patients who may not satisfy Medicare medical necessity criteria, or do not
meet critical care criteria or who do not have a critical care illness or injury and therefore
not eligible for critical care payment:
1. Patients admitted to a critical care unit because no other hospital beds were
available;
2. Patients admitted to a critical care unit for close nursing observation and/or
frequent monitoring of vital signs (e.g., drug toxicity or overdose); and
3. Patients admitted to a critical care unit because hospital rules require certain
treatments (e.g., insulin infusions) to be administered in the critical care unit.
Providing medical care to a critically ill patient should not be automatically deemed to be
a critical care service for the sole reason that the patient is critically ill or injured. While
more than one physician may provide critical care services to a patient during the critical
care episode of an illness or injury each physician must be managing one or more critical
illness(es) or injury(ies) in whole or in part.
EXAMPLE: A dermatologist evaluates and treats a rash on an ICU patient who is
maintained on a ventilator and nitroglycerine infusion that are being managed by an
intensivist. The dermatologist should not report a service for critical care.
C. Critical Care Services and Full Attention of the Physician
The duration of critical care services to be reported is the time the physician spent
evaluating, providing care and managing the critically ill or injured patient's care. That
time must be spent at the immediate bedside or elsewhere on the floor or unit so long as
the physician is immediately available to the patient.
For example, time spent reviewing laboratory test results or discussing the critically ill
patient's care with other medical staff in the unit or at the nursing station on the floor may
be reported as critical care, even when it does not occur at the bedside, if this time
represents the physician’s full attention to the management of the critically ill/injured
patient.
For any given period of time spent providing critical care services, the physician must
devote his or her full attention to the patient and, therefore, cannot provide services to
any other patient during the same period of time.
D. Critical Care Services and Qualified Non-Physician Practitioners (NPP)
Critical care services may be provided by qualified NPPs and reported for payment under
the NPP’s National Provider Identifier (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.
E. Critical Care Services and Physician Time
Critical care is a time- based service, and for each date and encounter entry, the
physician's progress note(s) shall document the total time that critical care services were
provided. More than one physician can provide critical care at another time and be paid
if the service meets critical care, is medically necessary and is not duplicative care.
Concurrent care by more than one physician (generally representing different physician
specialties) is payable if these requirements are met (refer to the Medicare Benefit Policy
Manual, Pub. 100-02, Chapter 15, §30 for concurrent care policy discussion).
The CPT critical care codes 99291 and 99292 are used to report the total duration of time
spent by a physician providing critical care services to a critically ill or critically injured
patient, even if the time spent by the physician on that date is not continuous. Non-
continuous time for medically necessary critical care services may be aggregated.
Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of
the same specialty within the same group practice bill and are paid as though they were a
single physician (§30.6.5).
1. Off the Unit/Floor
Time spent in activities (excluding those identified previously in Section C)
that occur outside of the unit or off the floor (i.e., telephone calls, whether
taken at home, in the office, or elsewhere in the hospital) may not be
reported as critical care because the physician is not immediately available
to the patient. This time is regarded as pre- and post service work bundled
in evaluation and management services.
2. Split/Shared Service
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) 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.
Unlike other E/M services where a split/shared service is allowed the critical
care service reported shall reflect the evaluation, treatment and management
of a patient by an individual physician or qualified non-physician
practitioner and shall not be representative of a combined service between a
physician and a qualified NPP.
When CPT code time requirements for both 99291 and 99292 and critical
care criteria are met for a medically necessary visit by a qualified NPP the
service shall be billed using the appropriate individual NPI number.
Medically necessary visit(s) that do not meet these requirements shall be
reported as subsequent hospital care services.
3. Unbundled Procedures
Time involved performing procedures that are not bundled into critical care
(i.e., billed and paid separately) may not be included and counted toward
critical care time. The physician's progress note(s) in the medical record
should document that time involved in the performance of separately
billable procedures was not counted toward critical care time.
4. Family Counseling/Discussions
Critical care CPT codes 99291 and 99292 include pre and post service work.
Routine daily updates or reports to family members and or surrogates are
considered part of this service. However, time involved with family
members or other surrogate decision makers, whether to obtain a history or
to discuss treatment options (as described in CPT), may be counted toward
critical care time when these specific criteria are met:
a) The patient is unable or incompetent to participate in giving a history
and/or making treatment decisions, and
b) The discussion is necessary for determining treatment decisions.
For family discussions, the physician should document:
a. The patient is unable or incompetent to participate in giving history
and/or making treatment decisions
b. The necessity to have the discussion (e.g., "no other source was
available to obtain a history" or "because the patient was
deteriorating so rapidly I needed to immediately discuss treatment
options with the family",
c. Medically necessary treatment decisions for which the discussion was
needed, and
d. A summary in the medical record that supports the medical
necessity of the discussion
All other family discussions, no matter how lengthy, may not be
additionally counted towards critical care. Telephone calls to
family members and or surrogate decision-makers may be counted
towards critical care time, but only if they meet the same criteria as
described in the aforementioned paragraph.
5. Inappropriate Use of Time for Payment of Critical Care Services.
Time involved in activities that do not directly contribute to the treatment
of the critically ill or injured patient may not be counted towards the
critical care time, even when they are performed in the critical care unit at
a patient's bedside (e.g., review of literature, and teaching sessions with
physician residents whether conducted on hospital rounds or in other
venues).
F. Hours and Days of Critical Care that May Be Billed
Critical care service is a time-based service provided on an hourly or fraction of an hour
basis. Payment should not be restricted to a fixed number of hours, a fixed number of
physicians, or a fixed number of days, on a per patient basis, for medically necessary
critical care services. Time counted towards critical care services may be continuous or
intermittent and aggregated in time increments (e.g., 50 minutes of continuous clock time
or (5) 10 minute blocks of time spread over a given calendar date). Only one physician
may bill for critical care services during any one single period of time even if more than
one physician is providing care to a critically ill patient.
For Medicare Part B physician services paid under the physician fee schedule, critical
care is not a service that is paid on a “shift” basis or a “per day” basis. Documentation
may be requested for any claim to determine medical necessity. Examples of critical care
billing that may require further review could include: claims from several physicians
submitting multiple units of critical care for a single patient, and submitting claims for
more than 12 hours of critical care time by a physician for one or more patients on the
same given calendar date. Physicians assigned to a critical care unit (e.g., hospitalist,
intensivist, etc.) may not report critical care for patients based on a ‘per shift” basis.
The CPT code 99291 is used to report the first 30 - 74 minutes of critical care on a given
calendar date of service. It should only be used once per calendar date per patient by the
same physician or physician group of the same specialty. CPT code 99292 is used to
report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of
critical care (See table below). 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 E/M code such as subsequent hospital care.
Clinical Example of Correct Billing of Time:
A patient arrives in the emergency department in cardiac arrest. The emergency
department physician provides 40 minutes of critical care services. A cardiologist is
called to the ED and assumes responsibility for the patient, providing 35 minutes of
critical care services. The patient stabilizes and is transferred to the CCU. In this
instance, the ED physician provided 40 minutes of critical care services and reports only
the critical care code (CPT code 99291) and not also emergency department services. The
cardiologist may report the 35 minutes of critical care services (also CPT code 99291)
provided in the ED. Additional critical care services by the cardiologist in the CCU may
be reported on the same calendar date using 99292 or another appropriate E/M code
depending on the clock time involved.
G. Counting of Units of Critical Care Services
The CPT code 99291 (critical care, first hour) is used to report the services of a
physician providing full attention to a critically ill or critically injured patient from 30-74
minutes on a given date. Only one unit of CPT code 99291 may be billed by a physician
for a patient on a given date. Physicians of the same specialty within the same group
practice bill and are paid as though they were a single physician and would not each
report CPT 99291on the same date of service.
The following table illustrates the correct reporting of critical care services:
Total Duration of Critical Care
Codes
Less than 30 minutes
99232 or 99233 or other appropriate E/M code
30 - 74 minutes
99291 x 1
75 - 104 minutes
99291 x 1 and 99292 x 1
105 - 134 minutes
99291 x1 and 99292 x 2
135 - 164 minutes
99291 x 1 and 99292 x 3
165 - 194 minutes
99291 x 1 and 99292 x 4
194 minutes or longer
99291 - 99292 as appropriate (per the above
illustrations)
H. Critical Care Services and Other Evaluation and Management Services Provided
on Same Day
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.
When critical care services are provided on a date where an inpatient hospital or
office/outpatient evaluation and management service was furnished earlier on the same
date at which time the patient did not require critical care, both the critical care and the
previous evaluation and management service may be paid. 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.
Physicians are advised to submit documentation to support a claim when critical care is
additionally reported on the same calendar date as when other evaluation and
management services are provided to a patient by the same physician or physicians of the
same specialty in a group practice.
I. Critical Care Services Provided by Physicians in Group Practice(s)
Medically necessary critical care services provided on the same calendar date to the same
patient by physicians representing different medical specialties that are not duplicative
services are payable. The medical specialists may be from the same group practice or
from different group practices.
Critically ill or critically injured patients may require the care of more than one physician
medical specialty. Concurrent critical care services provided by each physician must be
medically necessary and not provided during the same instance of time. Medical record
documentation must support the medical necessity of critical care services provided by
each physician (or qualified NPP). Each physician must accurately report the service(s)
he/she provided to the patient in accordance with any applicable global surgery rules or
concurrent care rules. (Refer to Medicare Claims Processing Manual, Pub. 100-04,
Chapter 12, §40, and the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15,
§30.)
CPT Code 99291
The initial critical care time, billed as CPT code 99291, must be met by a single physician
or 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 exam 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.
CPT Code 99292
Subsequent critical care visits performed on the same calendar date are reported using
CPT code 99292. The service may represent aggregate time met by a single physician or
physicians in the same group practice with the same medical specialty in order to meet
the duration of minutes required for CPT code 99292. The aggregated critical care visits
must be medically necessary and each aggregated visit must meet the definition of critical
care in order to combine the times.
Physicians in the same group practice who have the same specialty may not each report
CPT initial critical care code 99291 for critical care services to the same patient on the
same calendar date. Medicare payment policy states that physicians in the same group
practice who are in the same specialty must bill and be paid as though each were the
single physician. (Refer to the Medicare Claims Processing Manual, Pub. 100-04,
Chapter 12, §30.6.)
Physician specialty means the self-designated primary specialty by which the physician
bills Medicare and is known to the A/B MAC (B) that adjudicates the claims. Physicians
in the same group practice who have different medical specialties may bill and be paid
without regard to their membership in the same group. 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 (CPT 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.
Clinical Examples of Critical Care Services
1. Drs. Smith and Jones, pulmonary specialists, share a group practice. On Tuesday
Dr. Smith provides critical care services to Mrs. Benson who is comatose and has
been in the intensive care unit for 4 days following a motor vehicle accident. She
has multiple organ dysfunction including cerebral hematoma, flail chest and
pulmonary contusion. Later on the same calendar date Dr. Jones covers for Dr.
Smith and provides critical care services. Medically necessary critical care services
provided at the different time periods may be reported by both Drs. Smith and
Jones. Dr. Smith would report CPT code 99291 for the initial visit and Dr. Jones,
as part of the same group practice would report CPT code 99292 on the same
calendar date if the appropriate time requirements are met.
2. Mr. Marks, a 79 year old comes to the emergency room with vague joint pains and
lethargy. The ED physician evaluates Mr. Marks and phones his primary care
physician to discuss his medical evaluation. His primary care physician visits the
ER and admits Mr. Marks to the observation unit for monitoring, and diagnostic and
laboratory tests. In observation Mr. Marks has a cardiac arrest. His primary care
physician provides 50 minutes of critical care services. Mr. Marks’ is admitted to
the intensive care unit. On the same calendar day Mr. Marks’ condition deteriorates
and he requires intermittent critical care services. In this scenario the ED physician
should report an emergency department visit and the primary care physician should
report both an initial hospital visit and critical care services.
J. Critical Care Services and Other Procedures Provided on the Same Day by the
Same Physician as Critical Care Codes 99291 - 99292
The following services when performed on the day a physician bills for critical care are
included in the critical care service and should not be reported separately:
• The interpretation of cardiac output measurements (CPT 93561, 93562);
• Chest x-rays, professional component (CPT 71010, 71015, 71020);
• Blood draw for specimen (CPT 36415);
• Blood gases, and information data stored in computers (e.g., ECGs, blood
pressures, hematologic data-CPT 99090);
• Gastric intubation (CPT 43752, 91105);
• Pulse oximetry (CPT 94760, 94761, 94762);
• Temporary transcutaneous pacing (CPT 92953);
• Ventilator management (CPT 94002 - 94004, 94660, 94662); and
• Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600).
No other procedure codes are bundled into the critical care services. Therefore, other
medically necessary procedure codes may be billed separately.
K. Global Surgery
Critical care services shall not be paid on the same calendar date the physician also
reports a procedure code with a global surgical period unless the critical care is billed
with CPT modifier -25 to indicate that the critical care is a significant, separately
identifiable evaluation and management service that is above and beyond the usual pre
and post operative care associated with the procedure that is performed.
Services such as endotracheal intubation (CPT code 31500) and the insertion and
placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled
into the critical care codes. Therefore, separate payment may be made for critical care in
addition to these services if the critical care was a significant, separately identifiable
service and it was reported with modifier -25. The time spent performing the pre, intra,
and post procedure work of these unbundled services, e.g., endotracheal intubation, shall
be excluded from the determination of the time spent providing critical care.
This policy applies to any procedure with a 0, 10 or 90 day global period including
cardiopulmonary resuscitation (CPT code 92950). CPR has a global period of 0 days and
is not bundled into critical care codes. Therefore, critical care may be billed in addition
to CPR if critical care was a significant, separately identifiable service and it was
reported with modifier -25. The time spent performing CPR shall be excluded from the
determination of the time spent providing critical care. In this instance it must be the
physician who performs the resuscitation who bills for this service. Members of a code
team must not each bill Medicare Part B for this service.
When postoperative critical care services (for procedures with a global surgical period)
are provided by a physician other than the surgeon, no modifier is required unless all
surgical postoperative care has been officially transferred from the surgeon to the
physician performing the critical care services. In this situation, CPT modifiers "-54"
(surgical care only) and "-55"(postoperative management only) must be used by the
surgeon and intensivist who are submitting claims. Medical record documentation by the
surgeon and the physician who assumes a transfer (e.g., intensivist) is required to support
claims for services when CPT modifiers -54 and -55 are used indicating the transfer of
care from the surgeon to the intensivist. Critical care services must meet all the
conditions previously described in this manual section.
L. Critical Care Services Provided During Preoperative Portion and Postoperative
Portion of Global Period of Procedure with 90 Day Global Period in Trauma and
Burn Cases
Preoperative critical care and/or postoperative care may be paid in addition to a global fee
if the patient is critically ill and requires the full attention of the physician, and the critical
care is unrelated to the specific anatomic injury or general surgical procedure performed.
Such patients may meet the definition of being critically ill and criteria for conditions
where there is a high probability of imminent or life threatening deterioration in the
patient’s condition.
• For preoperative care modifier -25 (significant, separately identifiable evaluation
and management services by the same physician on the day of the procedure)
must be used with the HCPCS code
• For postoperative care modifier -24 (unrelated evaluation and management
service by the same physician during a postoperative period) must be used with
the HCPCS code.
In addition, for each preoperative and postoperative care the diagnosis must clearly
indicate that the critical care was unrelated to the surgery.
M. Teaching Physician Criteria
In order for the teaching physician to bill for critical care services the teaching physician
must meet the requirements for critical care described in the preceding sections. For CPT
codes determined on the basis of time, such as critical care, the teaching physician must
be present for the entire period of time for which the claim is submitted. For example,
payment will be made for 35 minutes of critical care services only if the teaching
physician is present for the full 35 minutes. (See IOM, Pub 100-04, Chapter12, § 100.1.4)
1. Teaching
Time spent teaching may not be counted towards critical care time. Time spent by the
resident, in the absence of the teaching physician, cannot be billed by the teaching
physician as critical care or other time-based services. Only time spent by the resident
and teaching physician together with the patient or the teaching physician alone with the
patient can be counted toward critical care time.
2. Documentation
A combination of the teaching physician’s documentation and the resident’s
documentation may support critical care services. Provided that all requirements for
critical care services are met, the teaching physician documentation may tie into the
resident's documentation. The teaching physician may refer to the resident’s
documentation for specific patient history, physical findings and medical assessment.
However, the teaching physician medical record documentation must provide substantive
information including: (1) the time the teaching physician spent providing critical care,
(2) that the patient was critically ill during the time the teaching physician saw the
patient, (3) what made the patient critically ill, and (4) the nature of the treatment and
management provided by the teaching physician. The medical review criteria are the
same for the teaching physician as for all physicians. (See the Medicare Claims
Processing, Pub. 100-04, Chapter 12, §100.1.1 for teaching physician documentation
guidance.)
Unacceptable Example of Documentation:
“I came and saw (the patient) and agree with (the resident)”.
Acceptable Example of Documentation:
"Patient developed hypotension and hypoxia; I spent 45 minutes while the patient
was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the
resident's documentation and I agree with the resident's assessment and plan of
care."
N. Ventilator Management
Medicare recognizes the ventilator codes (CPT codes 94002 - 94004, 94660 and 94662)
as physician services payable under the physician fee schedule. Medicare Part B under
the physician fee schedule does not pay for ventilator management services in addition to
an evaluation and management service (e.g., critical care services, CPT codes 99291 -
99292) on the same day for the patient even when the evaluation and management service
is billed with CPT modifier -25.
30.6.13 - Nursing Facility Services
(Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
A. Visits to Perform the Initial Comprehensive Assessment and Annual Assessments
The distinction made between the delegation of physician visits and tasks in a skilled
nursing facility (SNF) and in a nursing facility (NF) is based on the Medicare Statute.
Section 1819 (b) (6) (A) of the Social Security Act (the Act) governs SNFs while section
1919 (b) (6) (A) of the Act governs NFs. For further information refer to the Medicare
Learning Network article SE0418 at: http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNGenInfo/index.html?redirect=/MLNGenInfo
The federally mandated visits in a SNF and NF must be performed by the physician
except as otherwise permitted (42 CFR 483.40 (c) (4) and (f)). The principal physician of
record must append the modifier “-AI”, (Principal Physician of Record), to the initial
nursing facility care code. This modifier will identify the physician who oversees the
patient’s care from other physicians who may be furnishing specialty care. All other
physicians or qualified NPPs who perform an initial evaluation in the NF or SNF may bill
the initial nursing facility care code. The initial federally mandated visit is defined in
S&C-04-08 (see http://www.cms.gov/site-search/search-results.html?q=S%26C-04-08)
as the initial comprehensive visit during which the physician completes a thorough
assessment, develops a plan of care, and writes or verifies admitting orders for the
nursing facility resident. For Survey and Certification requirements, a visit must occur
no later than 30 days after admission.
Further, per the Long Term Care regulations at 42 CFR 483.40 (c) (4) and (e) (2), in a
SNF the physician may not delegate a task that the physician must personally perform.
Therefore, as stated in S&C-04-08 the physician may not delegate the initial federally
mandated comprehensive visit in a SNF.
The only exception, as to who performs the initial visit, relates to the NF setting. In the
NF setting, a qualified NPP (i.e., a nurse practitioner (NP), physician assistant (PA), or a
clinical nurse specialist (CNS)), who is not employed by the facility, may perform the
initial visit when the State law permits. The evaluation and management (E/M) visit shall
be within the State scope of practice and licensure requirements where the E/M visit is
performed and the requirements for physician collaboration and physician supervision
shall be met.
Under Medicare Part B payment policy, other medically necessary E/M visits may be
performed and reported prior to and after the initial visit, if the medical needs of the
patient require an E/M visit. A qualified NPP may perform medically necessary E/M
visits prior to and after the initial visit if all the requirements for collaboration, general
physician supervision, licensure, and billing are met.
The CPT Nursing Facility Services codes shall be used with place of service (POS) 31
(SNF) if the patient is in a Part A SNF stay. They shall be used with POS 32 (nursing
facility) if the patient does not have Part A SNF benefits or if the patient is in a NF or in a
non-covered SNF stay (e.g., there was no preceding 3-day hospital stay). The CPT
Nursing Facility code definition also includes POS 54 (Intermediate Care
Facility/Mentally Retarded) and POS 56 (Psychiatric Residential Treatment Center). For
further guidance on POS codes and associated CPT codes refer to §30.6.14.
Effective January 1, 2006, the Initial Nursing Facility Care codes 99301- 99303 are
deleted.
Beginning January 1, 2006, the new CPT codes, Initial Nursing Facility Care, per day,
(99304 - 99306) shall be used to report the initial federally mandated visit. Only a
physician may report these codes for an initial federally mandated visit performed in a
SNF or NF (with the exception of the qualified NPP in the NF setting who is not
employed by the facility and when State law permits, as explained above).
A readmission to a SNF or NF shall have the same payment policy requirements as an
initial admission in both the SNF and NF settings.
A physician who is employed by the SNF/NF may perform the E/M visits and bill
independently to Medicare Part B for payment. An NPP who is employed by the SNF or
NF may perform and bill Medicare Part B directly for those services where it is permitted
as discussed above. The employer of the PA shall always report the visits performed by
the PA. A physician, NP or CNS has the option to bill Medicare directly or to reassign
payment for his/her professional service to the facility.
As with all E/M visits for Medicare Part B payment policy, the E/M documentation
guidelines apply.
Medically Necessary Visits
Qualified NPPs may perform medically necessary E/M visits prior to and after the
physician’s initial federally mandated visit in both the SNF and NF. Medically necessary
E/M visits for the diagnosis or treatment of an illness or injury or to improve the
functioning of a malformed body member are payable under the physician fee schedule
under Medicare Part B. A physician or NPP may bill the most appropriate initial
nursing facility care code (CPT codes 99304-99306) or subsequent nursing facility
care code (CPT codes 99307-99310), even if the E/M service is provided prior to the
initial federally mandated visit.
SNF Setting--Place of Service Code 31
Following the initial federally mandated visit by the physician, the physician may
delegate alternate federally mandated physician visits to a qualified NPP who meets
collaboration and physician supervision requirements and is licensed as such by the State
and performing within the scope of practice in that State.
NF Setting--Place of Service Code 32
Per the regulations at 42 CFR 483.40 (f), a qualified NPP, who meets the collaboration
and physician supervision requirements, the State scope of practice and licensure
requirements, and who is not employed by the NF, may at the option of the State,
perform the initial federally mandated visit in a NF, and may perform any other federally
mandated physician visit in a NF in addition to performing other medically necessary
E/M visits.
Questions pertaining to writing orders or certification and recertification issues in the
SNF and NF settings shall be addressed to the appropriate State Survey and Certification
Agency departments for clarification.
B. Visits to Comply With Federal Regulations (42 CFR 483.40 (c) (1)) in the SNF
and NF
Payment is made under the physician fee schedule by Medicare Part B for federally
mandated visits. Following the initial federally mandated visit by the physician or
qualified NPP where permitted, payment shall be made for federally mandated visits that
monitor and evaluate residents at least once every 30 days for the first 90 days after
admission and at least once every 60 days thereafter.
Effective January 1, 2006, the Subsequent Nursing Facility Care, per day, codes 99311-
99313 are deleted.
Beginning January 1, 2006, the new CPT codes, Subsequent Nursing Facility Care, per
day, (99307 - 99310) shall be used to report federally mandated physician E/M visits and
medically necessary E/M visits.
A/B MACs (B) shall not pay for more than one E/M visit performed by the physician or
qualified NPP for the same patient on the same date of service. The Nursing Facility
Services codes represent a “per day” service.
The federally mandated E/M visit may serve also as a medically necessary E/M visit if
the situation arises (i.e., the patient has health problems that need attention on the day the
scheduled mandated physician E/M visit occurs). The physician/qualified NPP shall bill
only one E/M visit.
Beginning January 1, 2006, the new CPT code, Other Nursing Facility Service (99318),
may be used to report an annual nursing facility assessment visit on the required schedule
of visits on an annual basis. For Medicare Part B payment policy, an annual nursing
facility assessment visit code may substitute as meeting one of the federally mandated
physician visits if the code requirements for CPT code 99318 are fully met and in lieu of
reporting a Subsequent Nursing Facility Care, per day, service (codes 99307 - 99310). It
shall not be performed in addition to the required number of federally mandated
physician visits. The new CPT annual assessment code does not represent a new benefit
service for Medicare Part B physician services.
Qualified NPPs, whether employed or not by the SNF, may perform alternating federally
mandated physician visits, at the option of the physician, after the initial federally
mandated visit by the physician in a SNF.
Qualified NPPs in the NF setting, who are not employed by the NF and who are working
in collaboration with a physician, may perform federally mandated physician visits, at the
option of the State.
Medicare Part B payment policy does not pay for additional E/M visits that may be
required by State law for a facility admission or for other additional visits to satisfy
facility or other administrative purposes. E/M visits, prior to and after the initial federally
mandated physician visit, that are reasonable and medically necessary to meet the
medical needs of the individual patient (unrelated to any State requirement or
administrative purpose) are payable under Medicare Part B.
C. Visits by Qualified Nonphysician Practitioners
All E/M visits shall be within the State scope of practice and licensure requirements
where the visit is performed and all the requirements for physician collaboration and
physician supervision shall be met when performed and reported by qualified NPPs.
General physician supervision and employer billing requirements shall be met for PA
services in addition to the PA meeting the State scope of practice and licensure
requirements where the E/M visit is performed.
Medically Necessary Visits
Qualified NPPs may perform medically necessary E/M visits prior to and after the
physician’s initial visit in both the SNF and NF. Medically necessary E/M visits for the
diagnosis or treatment of an illness or injury or to improve the functioning of a
malformed body member are payable under the physician fee schedule under Medicare
Part B. A physician or NPP may bill the most appropriate initial nursing facility
care code (CPT codes 99304-99306) or subsequent nursing facility care code (CPT
codes 99307-99310), even if the E/M service is provided prior to the initial federally
mandated visit.
SNF Setting--Place of Service Code 31
Following the initial federally mandated visit by the physician, the physician may
delegate alternate federally mandated physician visits to a qualified NPP who meets
collaboration and physician supervision requirements and is licensed as such by the State
and performing within the scope of practice in that State.
NF Setting--Place of Service Code 32
Per the regulations at 42 CFR 483.40 (f), a qualified NPP, who meets the collaboration
and physician supervision requirements, the State scope of practice and licensure
requirements, and who is not employed by the NF, may at the option of the State,
perform the initial federally mandated visit in a NF, and may perform any other federally
mandated physician visit in a NF in addition to performing other medically necessary
E/M visits.
Questions pertaining to writing orders or certification and recertification issues in the
SNF and NF settings shall be addressed to the appropriate State Survey and Certification
Agency departments for clarification.
D. Medically Complex Care
Payment is made for E/M visits to patients in a SNF who are receiving services for
medically complex care upon discharge from an acute care facility when the visits are
reasonable and medically necessary and documented in the medical record. Physicians
and qualified NPPs shall report initial nursing facility care codes for their first visit with
the patient. The principal physician of record must append the modifier “-AI” (Principal
Physician of Record), to the initial nursing facility care code when billed to identify the
physician who oversees the patient’s care from other physicians who may be furnishing
specialty care. Follow-up visits shall be billed as subsequent nursing facility care visits.
E. Incident to Services
Where a physician establishes an office in a SNF/NF, the “incident to” services and
requirements are confined to this discrete 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 shall not be reported using the CPT codes for
office or other outpatient visits or use place of service code 11.
F. Use of the Prolonged Services Codes and Other Time-Related Services
Beginning January 1, 2008, typical/average time units for E/M visits in the SNF/NF
settings are reestablished. Medically necessary prolonged services for E/M visits (codes
99356 and 99357) in a SNF or NF may be billed with the Nursing Facility Services in the
code ranges (99304 - 99306, 99307 - 99310 and 99318).
Counseling and Coordination of Care Visits
With the reestablishment of typical/average time units, medically necessary E/M visits
for counseling and coordination of care, for Nursing Facility Services in the code ranges
(99304 - 99306, 99307 - 99310 and 99318) that are time-based services, may be billed
with the appropriate prolonged services codes (99356 and 99357).
G. Multiple Visits
The complexity level of an E/M visit and the CPT code billed must be a covered and
medically necessary visit for each patient (refer to §§1862 (a)(1)(A) of the Act). Claims
for an unreasonable number of daily E/M visits by the same physician to multiple patients
at a facility within a 24-hour period may result in medical review to determine medical
necessity for the visits. The E/M visit (Nursing Facility Services) represents a “per day”
service per patient as defined by the CPT code. The medical record must be personally
documented by the physician or qualified NPP who performed the E/M visit and the
documentation shall support the specific level of E/M visit to each individual patient.
H. Split/Shared E/M Visit
A split/shared E/M visit cannot be reported in the SNF/NF setting. 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
the qualified NPP must be in the same group practice or be 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.
I. SNF/NF Discharge Day Management Service
Medicare Part B payment policy requires a face-to-face visit with the patient provided by
the physician or the qualified NPP to meet the SNF/NF discharge day management
service as defined by the CPT code. The E/M discharge day management visit shall be
reported for the date of the actual visit by the physician or qualified NPP even if the
patient is discharged from the facility on a different calendar date. The CPT codes 99315
- 99316 shall be reported for this visit. The Discharge Day Management Service may be
reported using CPT code 99315 or 99316, depending on the code requirement, for a
patient who has expired, but only if the physician or qualified NPP personally performed
the death pronouncement.
30.6.14 - Home Care and Domiciliary Care Visits (Codes 99324- 99350)
(Rev. 775, Issued: 12-02-05, Effective: 01-01-06, Implementation: 01-03-06)
Physician Visits to Patients Residing in Various Places of Service
The American Medical Association’s Current Procedural Terminology (CPT) 2006 new
patient codes 99324 - 99328 and established patient codes 99334 - 99337(new codes
beginning January 2006), for Domiciliary, Rest Home (e.g., Boarding Home), or
Custodial Care Services, are used to report evaluation and management (E/M) services to
residents residing in a facility which provides room, board, and other personal assistance
services, generally on a long-term basis. These CPT codes are used to report E/M
services in facilities assigned places of service (POS) codes 13 (Assisted Living Facility),
14 (Group Home), 33 (Custodial Care Facility) and 55 (Residential Substance Abuse
Facility). Assisted living facilities may also be known as adult living facilities.
Physicians and qualified nonphysician practitioners (NPPs) furnishing E/M services to
residents in a living arrangement described by one of the POS listed above must use the
level of service code in the CPT code range 99324 - 99337 to report the service they
provide. The CPT codes 99321 - 99333 for Domiciliary, Rest Home (e.g., Boarding
Home), or Custodial Care Services are deleted beginning January, 2006.
Beginning in 2006, reasonable and medically necessary, face-to-face, prolonged services,
represented by CPT codes 99354 - 99355, may be reported with the appropriate
companion E/M codes when a physician or qualified NPP, provides a prolonged service
involving direct (face-to-face) patient contact that is beyond the usual E/M visit service
for a Domiciliary, Rest Home (e.g., Boarding Home) or Custodial Care Service. All the
requirements for prolonged services at §30.6.15.1 must be met.
The CPT codes 99341 through 99350, Home Services codes, are used to report E/M
services furnished to a patient residing in his or her own private residence (e.g., private
home, apartment, town home) and not residing in any type of congregate/shared facility
living arrangement including assisted living facilities and group homes. The Home
Services codes apply only to the specific 2-digit POS 12 (Home). Home Services codes
may not be used for billing E/M services provided in settings other than in the private
residence of an individual as described above.
Beginning in 2006, E/M services provided to patients residing in a Skilled Nursing
Facility (SNF) or a Nursing Facility (NF) must be reported using the appropriate CPT
level of service code within the range identified for Initial Nursing Facility Care (new
CPT codes 99304 - 99306) and Subsequent Nursing Facility Care (new CPT codes 99307
- 99310). Use the CPT code, Other Nursing Facility Services (new CPT code 99318), for
an annual nursing facility assessment. Use CPT codes 99315 - 99316 for SNF/NF
discharge services. The CPT codes 99301 - 99303 and 99311 - 99313 are deleted
beginning January, 2006. The Home Services codes should not be used for these places
of service.
The CPT SNF/NF code definition includes intermediate care facilities (ICFs) and long
term care facilities (LTCFs). These codes are limited to the specific 2-digit POS 31
(SNF), 32 (Nursing Facility), 54 (Intermediate Care Facility/Mentally Retarded) and 56
(Psychiatric Residential Treatment Center).
The CPT nursing facility codes should be used with POS 31 (SNF) if the patient is in a
Part A SNF stay and POS 32 (nursing facility) if the patient does not have Part A SNF
benefits. There is no longer a different payment amount for a Part A or Part B benefit
period in these POS settings.
30.6.14.1 - Home Services (Codes 99341 - 99350)
(Rev. 1, 10-01-03)
B3-15515, B3-15066
A. Requirement for Physician Presence
Home services codes 99341-99350 are paid when they are billed to report evaluation and
management services provided in a private residence. A home visit cannot be billed by a
physician unless the physician was actually present in the beneficiary’s home.
B. Homebound Status
Under the home health benefit the beneficiary must be confined to the home for services
to be covered. For home services provided by a physician using these codes, the
beneficiary does not need to be confined to the home. The medical record must
document the medical necessity of the home visit made in lieu of an office or outpatient
visit.
C. Fee Schedule Payment for Services to Homebound Patients under General
Supervision
Payment may be made in some medically underserved areas where there is a lack of
medical personnel and home health services for injections, EKGs, and venipunctures that
are performed for homebound patients under general physician supervision by nurses and
paramedical employees of physicians or physician-directed clinics. Section 10 provides
additional information on the provision of services to homebound Medicare patients.
30.6.15 - Prolonged Services and Standby Services (Codes
99354 - 99360)
(Rev. 1, 10-01-03)
B3-15511-15511.3
30.6.15.1 - Prolonged Services With Direct Face-to-Face Patient Contact
Service (ZZZ codes)
(Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
A. Definition
Prolonged physician services (CPT code 99354) in the office or other outpatient setting
with direct face-to-face patient contact which require 1 hour beyond the usual service are
payable when billed on the same day by the same physician or qualified nonphysician
practitioner (NPP) as the companion evaluation and management codes. The time for
usual service refers to the typical/average time units associated with the companion
evaluation and management service as noted in the CPT code. Each additional 30
minutes of direct face-to-face patient contact following the first hour of prolonged
services may be reported by CPT code 99355.
Prolonged physician services (code 99356) in the inpatient setting, with direct face-to-
face patient contact which require 1 hour beyond the usual service are payable when they
are billed on the same day by the same physician or qualified NPP as the companion
evaluation and management codes. Each additional 30 minutes of direct face-to-face
patient contact following the first hour of prolonged services may be reported by CPT
code 99357.
Prolonged service of less than 30 minutes total duration on a given date is not separately
reported because the work involved is included in the total work of the evaluation and
management codes.
Code 99355 or 99357 may be used to report each additional 30 minutes beyond the first
hour of prolonged services, based on the place of service. These codes may be used to
report the final 15 - 30 minutes of prolonged service on a given date, if not otherwise
billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15
minutes beyond the final 30 minutes is not reported separately.
B. Required Companion Codes
The companion evaluation and management codes for 99354 are the Office or Other
Outpatient visit codes (99201 - 99205, 99212 - 99215), the Domiciliary, Rest Home, or
Custodial Care Services codes (99324 - 99328, 99334 - 99337), the Home Services codes
(99341 - 99345, 99347 - 99350);
The companion codes for 99355 are 99354 and one of the evaluation and management
codes required for 99354 to be used;
The companion evaluation and management codes for 99356 are the Initial Hospital Care
codes and Subsequent Hospital Care codes (99221 - 99223, 99231 - 99233); Nursing
Facility Services codes (99304 -99318); or
The companion codes for 99357 are 99356 and one of the evaluation and management
codes required for 99356 to be used.
Prolonged services codes 99354 - 99357 are not paid unless they are accompanied by the
companion codes as indicated.
C. Requirement for Physician Presence
Physicians may count only the duration of direct face-to-face contact between the
physician and the patient (whether the service was continuous or not) beyond the
typical/average time of the visit code billed to determine whether prolonged services can
be billed and to determine the prolonged services codes that are allowable. In the case of
prolonged office services, time spent by office staff with the patient, or time the patient
remains unaccompanied in the office cannot be billed. In the case of prolonged hospital
services, time spent reviewing charts or discussion of a patient with house medical staff
and not with direct face-to-face contact with the patient, or waiting for test results, for
changes in the patient’s condition, for end of a therapy, or for use of facilities cannot be
billed as prolonged services.
D. Documentation
Documentation is not required to accompany the bill for prolonged services unless the
physician has been selected for medical review. Documentation is required in the
medical record about the duration and content of the medically necessary evaluation and
management service and prolonged services billed. The medical record must be
appropriately and sufficiently documented by the physician or qualified NPP to show that
the physician or qualified NPP personally furnished the direct face-to-face time with the
patient specified in the CPT code definitions. The start and end times of the visit shall be
documented in the medical record along with the date of service.
E. Use of the Codes
Prolonged services codes can be billed only if the total duration of the physician or
qualified NPP direct face-to-face service (including the visit) equals or exceeds the
threshold time for the evaluation and management service the physician or qualified NPP
provided (typical/average time associated with the CPT E/M code plus 30 minutes). If
the total duration of direct face-to-face time does not equal or exceed the threshold time
for the level of evaluation and management service the physician or qualified NPP
provided, the physician or qualified NPP may not bill for prolonged services.
F. Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)
If the total direct face-to-face time equals or exceeds the threshold time for code 99354,
but is less than the threshold time for code 99355, the physician should bill the evaluation
and management visit code and code 99354. No more than one unit of 99354 is
acceptable. If the total direct face-to-face time equals or exceeds the threshold time for
code 99355 by no more than 29 minutes, the physician should bill the visit code 99354
and one unit of code 99355. One additional unit of code 99355 is billed for each
additional increment of 30 minutes extended duration. A/B MACs (B) use the following
threshold times to determine if the prolonged services codes 99354 and/or 99355 can be
billed with the office or other outpatient settings including domiciliary, rest home, or
custodial care services and home services codes.
Threshold Time for Prolonged Visit Codes 99354 and/or 99355 Billed with
Office/Outpatient
Code
Typical Time
for Code
Threshold Time
to Bill Code
99354
Threshold Time
to Bill Codes
99354 and
99355
99201
10
40
85
99202
20
50
95
99203
30
60
105
99204
45
75
120
99205
60
90
135
Code
Typical Time
for Code
Threshold Time
to Bill Code
99354
Threshold Time
to Bill Codes
99354 and
99355
99212
10
40
85
99213
15
45
90
99214
25
55
100
99215
40
70
115
99324
20
50
95
99325
30
60
105
99326
45
75
120
99327
60
90
135
99328
75
105
150
99334
15
45
90
99335
25
55
100
99336
40
70
115
99337
60
90
135
99341
20
50
95
99342
30
60
105
99343
45
75
120
99344
60
90
135
99345
75
105
150
99347
15
45
90
99348
25
55
100
99349
40
70
115
99350
60
90
135
Add 30 minutes to the threshold time for billing codes 99354 and 99355 to get the
threshold time for billing code 99354 and two units of code 99355. For example, to bill
code 99354 and two units of code 99355 when billing a code 99205, the threshold time is
150 minutes.
G. Threshold Times for Codes 99356 and 99357
(Inpatient Setting) If the total direct face-to-face time equals or exceeds the threshold
time for code 99356, but is less than the threshold time for code 99357, the physician
should bill the visit and code 99356. A/B MACs (B) do not accept more than one unit of
code 99356. If the total direct face-to-face time equals or exceeds the threshold time for
code 99356 by no more than 29 minutes, the physician bills the visit code 99356 and one
unit of code 99357. One additional unit of code 99357 is billed for each additional
increment of 30 minutes extended duration. A/B MACs (B) use the following threshold
times to determine if the prolonged services codes 99356 and/or 99357 can be billed with
the inpatient setting codes.
Threshold Time for Prolonged Visit Codes 99356 and/or 99357 Billed with Inpatient
Setting Codes
Code
Typical Time for
Code
Threshold Time to Bill
Code 99356
Threshold Time to Bill
Codes 99356 and 99357
99221
30
60
105
99222
50
80
125
99223
70
100
145
99231
15
45
90
99232
25
55
100
Add 30 minutes to the threshold time for billing codes 99356 and 99357 to get the
threshold time for billing code 99356 and two units of 99357.
H. Prolonged Services Associated With Evaluation and Management Services Based
on Counseling and/or Coordination of Care (Time-Based)
When an evaluation and management service is dominated by counseling and/or
coordination of care (the counseling and/or coordination of care represents more than
50% of the total time with the patient) in a face-to-face encounter between the physician
or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an
inpatient service), then the evaluation and management code is selected based on the
typical/average time associated with the code levels. The time approximation must meet
or exceed the specific CPT code billed (determined by the typical/average time associated
with the evaluation and management code) and should not be “rounded” to the next
higher level.
In those evaluation and management services in which the code level is selected based on
time, prolonged services may only be reported with the highest code level in that family
of codes as the companion code.
I. Examples of Billable Prolonged Services
EXAMPLE 1
A physician performed a visit that met the definition of an office visit code 99213 and the
total duration of the direct face-to-face services (including the visit) was 65 minutes. The
physician bills code 99213 and one unit of code 99354.
EXAMPLE 2
A physician performed a visit that met the definition of a domiciliary, rest home care visit
code 99327 and the total duration of the direct face-to-face contact (including the visit)
was 140 minutes. The physician bills codes 99327, 99354, and one unit of code 99355.
EXAMPLE 3
A physician performed an office visit to an established patient that was predominantly
counseling, spending 75 minutes (direct face-to-face) with the patient. The physician
should report CPT code 99215 and one unit of code 99354.
J. Examples of Nonbillable Prolonged Services
EXAMPLE 1
A physician performed a visit that met the definition of visit code 99212 and the total
duration of the direct face-to-face contact (including the visit) was 35 minutes. The
physician cannot bill prolonged services because the total duration of direct face-to-face
service did not meet the threshold time for billing prolonged services.
EXAMPLE 2
A physician performed a visit that met the definition of code 99213 and, while the patient
was in the office receiving treatment for 4 hours, the total duration of the direct face-to-
face service of the physician was 40 minutes. The physician cannot bill prolonged
services because the total duration of direct face-to-face service did not meet the
threshold time for billing prolonged services.
EXAMPLE 3
A physician provided a subsequent office visit that was predominantly counseling,
spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214,
which has a typical time of 25 minutes, and one unit of code 99354. The physician must
bill the highest level code in the code family (99215 which has 40 minutes
typical/average time units associated with it). The additional time spent beyond this code
is 20 minutes and does not meet the threshold time for billing prolonged services.
30.6.15.2 - Prolonged Services Without Direct Face-to-Face Patient
Contact Service (Codes 99358 - 99359)
(Rev. 3678, Issued: 12-16-16, Effective: 01-01-17, Implementation: 01-03-17)
Until CY 2017, CPT codes 99358 and 99359 were not separately payable and were
bundled (included for payment) under the related face-to-face E/M service code.
Practitioners were not permitted to bill the patient for services described by CPT codes
99358 and 99359 since they are Medicare covered services and payment was included in
the payment for other billable services.
Beginning in CY 2017, CPT codes 99358 and 99359 are separately payable under the
physician fee schedule. The CPT prefatory language and reporting rules for these codes
apply for Medicare billing. For example, CPT codes 99358 and 99359 cannot be
reported during the same service period as complex chronic care management (CCM)
services or transitional care management services. They are not reported for time spent
in non-face-to-face care described by more specific codes having no upper time limit in
the CPT code set. We have posted a file that notes the times assumed to be typical for
purposes of PFS rate-setting. That file is available on our website under downloads for
our annual regulation at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. We note that while
these typical times are not required to bill the displayed codes, we would expect that only
time spent in excess of these times would be reported under CPT codes 99358 and 99359.
We note that CPT codes 99358 and 99359 can only be used to report extended qualifying
time of the billing physician or other practitioner (not clinical staff). Prolonged services
cannot be reported in association with a companion E/M code that also qualifies as the
initiating visit for CCM services. Practitioners should instead report the add-on code for
CCM initiation, if applicable.
30.6.15.3 - Physician Standby Service (Code 99360)
(Rev. 1, 10-01-03)
Standby services are not payable to physicians. Physicians may not bill Medicare or
beneficiaries for standby services. Payment for standby services is included in the Part A
payment to the facility. Such services are a part of hospital costs to provide quality care.
If hospitals pay physicians for standby services, such services are part of hospital costs to
provide quality care.
30.6.15.4 - Power Mobility Devices (PMDs) (Code G0372)
(Rev. 748, Issued: 11-04-05; Effective/Implementation Dates: 10-25-05)
Section 302(a)(2)(E)(iv) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) sets forth revised conditions for Medicare payment
of Power Mobility Devices (PMDs). This section of the MMA states that payment for
motorized or power wheelchairs may not be made unless a physician (as defined in
§1861(r)(1) of the Act), a physician assistant, nurse practitioner, or a clinical nurse
specialist (as those terms are defined in §1861(aa)(5)) has conducted a face-to-face
examination of the beneficiary and written a prescription for the PMD.
Payment for the history and physical examination will be made through the appropriate
evaluation and management (E&M) code corresponding to the history and physical
examination of the patient. Due to the MMA requirement that the physician or treating
practitioner create a written prescription and a regulatory requirement that the physician
or treating practitioner prepare pertinent parts of the medical record for submission to the
durable medical equipment supplier, code G0372 (physician service required to establish and
document the need for a power mobility device) has been established to recognize additional
physician services and resources required to establish and document the need for the
PMD.
The G code indicates that all of the information necessary to document the PMD
prescription is included in the medical record, and the prescription and supporting
documentation is delivered to the PMD supplier within 30 days after the face-to-face
examination.
Effective October 25, 2005, G0372 will be used to recognize additional physician
services and resources required to establish and document the need for the PMD and will
be added to the Medicare physician fee schedule.
30.6.16 - Case Management Services (Codes 99362 and 99371 - 99373)
(Rev. 1, 10-01-03)
B3-15512
A. Team Conferences
Team conferences (codes 99361-99362) may not be paid separately. Payment for these
services is included in the payment for the services to which they relate.
B. Telephone Calls
Telephone calls (codes 99371-99373) may not be paid separately. Payment for telephone
calls is included in payment for billable services (e.g., visit, surgery, diagnostic procedure
results).
40 - Surgeons and Global Surgery
(Rev. 1, 10-01-03)
B3-4820
A national definition of a global surgical package has been established to ensure that
payment is made consistently for the same services across all A/B MAC (B) jurisdictions,
thus preventing Medicare payments for services that are more or less comprehensive than
intended. The national global surgery policy became effective for surgeries performed on
and after January 1, 1992.
The instructions that follow describe the components of a global surgical package and
payment rules for minor surgeries, endoscopies and global surgical packages that are split
between two or more physicians. In addition, billing, mandatory edits, claims review,
adjudication, and postpayment instructions are included.
In addition to the global policy, uniform payment policies and claims processing
requirements have been established for other surgical issues, including bilateral and
multiple surgeries, co-surgeons, and team surgeries.
40.1 - Definition of a Global Surgical Package
(Rev. 1, 10-01-03)
B3-4821, B3-15900.2
Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative
periods that apply to each surgical procedure. The payment rules for surgical procedures
apply to codes with entries of 000, 010, 090, and, sometimes, YYY.
Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either
minor surgical procedures or endoscopies.
Codes with “YYY” are A/B MAC (B)-priced codes, for which A/B MACs (B) determine
the global period (the global period for these codes will be 0, 10, or 90 days). Note that
not all A/B MAC (B)-priced codes have a “YYY” global surgical indicator; sometimes
the global period is specified.
While codes with “ZZZ” are surgical codes, they are add-on codes that are always billed
with another service. There is no postoperative work included in the fee schedule
payment for the “ZZZ” codes. Payment is made for both the primary and the add-on
codes, and the global period assigned is applied to the primary code.
A. Components of a Global Surgical Package
B3-15011, B3-4820-4831
A/B MACs (B) apply the national definition of a global surgical package to all
procedures with the appropriate entry in Field 16 of the MFSDB.
The Medicare approved amount for these procedures includes payment for the following
services related to the surgery when furnished by the physician who performs the surgery.
The services included in the global surgical package may be furnished in any setting, e.g.,
in hospitals, ASCs, physicians’ offices. Visits to a patient in an intensive care or critical
care unit are also included if made by the surgeon. However, critical care services
(99291 and 99292) are payable separately in some situations.
• Preoperative Visits - Preoperative visits after the decision is made to operate
beginning with the day before the day of surgery for major procedures and the day
of surgery for minor procedures;
• Intra-operative Services - Intra-operative services that are normally a usual and
necessary part of a surgical procedure;
• Complications Following Surgery - All additional medical or surgical services
required of the surgeon during the postoperative period of the surgery because of
complications which do not require additional trips to the operating room;
• Postoperative Visits - Follow-up visits during the postoperative period of the
surgery that are related to recovery from the surgery;
• Postsurgical Pain Management - By the surgeon;
• Supplies - Except for those identified as exclusions; and
• Miscellaneous Services - Items such as dressing changes; local incisional care;
removal of operative pack; removal of cutaneous sutures and staples, lines, wires,
tubes, drains, casts, and splints; insertion, irrigation and removal of urinary
catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and
changes and removal of tracheostomy tubes.
B. Services Not Included in the Global Surgical Package
A/B MACs (B) do not include the services listed below in the payment amount for a
procedure with the appropriate indicator in Field 16 of the MFSDB. These services may
be paid for separately.
• The initial consultation or evaluation of the problem by the surgeon to determine
the need for surgery. Please note that this policy only applies to major surgical
procedures. The initial evaluation is always included in the allowance for a minor
surgical procedure;
• Services of other physicians except where the surgeon and the other physician(s)
agree on the transfer of care. This agreement may be in the form of a letter or an
annotation in the discharge summary, hospital record, or ASC record;
• Visits unrelated to the diagnosis for which the surgical procedure is performed,
unless the visits occur due to complications of the surgery;
• Treatment for the underlying condition or an added course of treatment which is
not part of normal recovery from surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period which are not
re-operations or treatment for complications. (A new postoperative period begins
with the subsequent procedure.) This includes procedures done in two or more
parts for which the decision to stage the procedure is made prospectively or at the
time of the first procedure. Examples of this are procedures to diagnose and treat
epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be
performed in succession within 90 days of each other;
• Treatment for postoperative complications which requires a return trip to the
operating room (OR). An OR for this purpose is defined as a place of service
specifically equipped and staffed for the sole purpose of performing procedures.
The term includes a cardiac catheterization suite, a laser suite, and an endoscopy
suite. It does not include a patient’s room, a minor treatment room, a recovery
room, or an intensive care unit (unless the patient’s condition was so critical there
would be insufficient time for transportation to an OR);
• If a less extensive procedure fails, and a more extensive procedure is required, the
second procedure is payable separately;
• For certain services performed in a physician’s office, separate payment can no
longer be made for a surgical tray (code A4550). This code is now a Status B and
is no longer a separately payable service on or after January 1, 2002. However,
splints and casting supplies are payable separately under the reasonable charge
payment methodology;
• Immunosuppressive therapy for organ transplants; and
• Critical care services (codes 99291 and 99292) unrelated to the surgery where a
seriously injured or burned patient is critically ill and requires constant attendance
of the physician.
C. Minor Surgeries and Endoscopies
Visits by the same physician on the same day as a minor surgery or endoscopy are
included in the payment for the procedure, unless a significant, separately identifiable
service is also performed. For example, a visit on the same day could be properly billed
in addition to suturing a scalp wound if a full neurological examination is made for a
patient with head trauma. Billing for a visit would not be appropriate if the physician
only identified the need for sutures and confirmed allergy and immunization status.
A postoperative period of 10 days applies to some minor surgeries. The postoperative
period for these procedures is indicated in Field 16 of the MFSDB. If the Field 16 entry
is 010, A/B MACs (B) do not allow separate payment for postoperative visits or services
within 10 days of the surgery that are related to recovery from the procedure. If a
diagnostic biopsy with a 10-day global period precedes a major surgery on the same day
or in the 10-day period, the major surgery is payable separately. Services by other
physicians are not included in the global fee for a minor procedures except as otherwise
excluded. If the Field 16 entry is 000, postoperative visits beyond the day of the
procedure are not included in the payment amount for the surgery. Separate payment is
made in this instance.
D. Physicians Furnishing Less Than the Full Global Package
B3-4820-4831
There are occasions when more than one physician provides services included in the
global surgical package. It may be the case that the physician who performs the surgical
procedure does not furnish the follow-up care. Payment for the postoperative, post-
discharge care is split between two or more physicians where the physicians agree on the
transfer of care.
When more than one physician furnishes services that are included in the global surgical
package, the sum of the amount approved for all physicians may not exceed what would
have been paid if a single physician provides all services (except where stated policies,
e.g., the surgeon performs only the surgery and a physician other than the surgeon
provides preoperative and postoperative inpatient care, result in payment that is higher
than the global allowed amount).
Where a transfer of care does not occur, the services of another physician may either be
paid separately or denied for medical necessity reasons, depending on the circumstances
of the case.
E. Determining the Duration of a Global Period
To determine the global period for major surgeries, A/B MACs (B) count 1 day
immediately before the day of surgery, the day of surgery, and the 90 days immediately
following the day of surgery.
EXAMPLE:
Date of surgery - January 5
Preoperative period - January 4
Last day of postoperative period - April 5
To determine the global period for minor procedures, A/B MACs (B) count the day of
surgery and the appropriate number of days immediately following the date of surgery.
EXAMPLE:
Procedure with 10 follow-up days:
Date of surgery - January 5
Last day of postoperative period - January 15
40.2 - Billing Requirements for Global Surgeries
(Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-
2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of
ICD-10)
To ensure the proper identification of services that are, or are not, included in the global
package, the following procedures apply.
A. Procedure Codes and Modifiers
Use of the modifiers in this section apply to both major procedures with a 90-day
postoperative period and minor procedures with a 10-day postoperative period (and/or a
zero day postoperative period in the case of modifiers “-22” and “-25”).
1. Physicians Who Furnish the Entire Global Surgical Package
Physicians who perform the surgery and furnish all of the usual pre-and postoperative
work bill for the global package by entering the appropriate CPT code for the surgical
procedure only. Billing is not allowed for visits or other services that are included in the
global package.
2. Physicians in Group Practice
When different physicians in a group practice participate in the care of the patient, the
group bills for the entire global package if the physicians reassign benefits to the group.
The physician who performs the surgery is shown as the performing physician. (For
dates of service prior to January 1, 1994, however, where a new physician furnishes the
entire postoperative care, the group billed for the surgical care and the postoperative care
as separate line items with the appropriate modifiers.)
3. Physicians Who Furnish Part of a Global Surgical Package
Where physicians agree on the transfer of care during the global period, the following
modifiers are used:
• “-54” for surgical care only; or
• “-55” for postoperative management only.
Both the bill for the surgical care only and the bill for the postoperative care only, will
contain the same date of service and the same surgical procedure code, with the services
distinguished by the use of the appropriate modifier.
Providers need not specify on the claim that care has been transferred. However, the date
on which care was relinquished or assumed, as applicable, must be shown on the claim.
This should be indicated in the remarks field/free text segment on the claim form/format.
Both the surgeon and the physician providing the postoperative care must keep a copy of
the written transfer agreement in the beneficiary’s medical record.
Where a transfer of postoperative care occurs, the receiving physician cannot bill for any
part of the global services until he/she has provided at least one service. Once the
physician has seen the patient, that physician may bill for the period beginning with the
date on which he/she assumes care of the patient.
EXCEPTIONS:
• Where a transfer of care does not occur, occasional post-discharge services of a
physician other than the surgeon are reported by the appropriate evaluation and
management code. No modifiers are necessary on the claim.
• If the transfer of care occurs immediately after surgery, the physician other than
the surgeon who provides the in-hospital postoperative care bills using subsequent
hospital care codes for the inpatient hospital care and the surgical code with the “-
55” modifier for the post-discharge care. The surgeon bills the surgery code with
the “-54” modifier.
• Physicians who provide follow-up services for minor procedures performed in
emergency departments bill the appropriate level of office visit code. The
physician who performs the emergency room service bills for the surgical
procedure without a modifier.
• If the services of a physician other than the surgeon are required during a
postoperative period for an underlying condition or medical complication, the
other physician reports the appropriate evaluation and management code. No
modifiers are necessary on the claim. An example is a cardiologist who manages
underlying cardiovascular conditions of a patient.
4. Evaluation and Management Service Resulting in the Initial Decision to Perform
Surgery
Evaluation and management services on the day before major surgery or on the day of
major surgery that result in the initial decision to perform the surgery are not included in
the global surgery payment for the major surgery and, therefore, may be billed and paid
separately.
In addition to the CPT evaluation and management code, modifier “-57” (decision for
surgery) is used to identify a visit which results in the initial decision to perform surgery.
(Modifier “-QI” was used for dates of service prior to January 1, 1994.)
If evaluation and management services occur on the day of surgery, the physician bills
using modifier “-57,” not “-25.” The “-57” modifier is not used with minor surgeries
because the global period for minor surgeries does not include the day prior to the
surgery. Moreover, where the decision to perform the minor procedure is typically done
immediately before the service, it is considered a routine preoperative service and a visit
or consultation is not billed in addition to the procedure.
5. Return Trips to the Operating Room During the Postoperative Period
When treatment for complications requires a return trip to the operating room, physicians
must bill the CPT code that describes the procedure(s) performed during the return trip.
If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999
or 64999. The procedure code for the original surgery is not used except when the
identical procedure is repeated.
In addition to the CPT code, physicians use CPT modifier “-78” for these return trips
(return to the operating room for a related procedure during a postoperative period.)
The physician may also need to indicate that another procedure was performed during the
postoperative period of the initial procedure. When this subsequent procedure is related
to the first procedure and requires the use of the operating room, this circumstance may
be reported by adding the modifier “-78” to the related procedure.
NOTE: The CPT definition for this modifier does not limit its use to treatment for
complications.
6. Staged or Related Procedures
Modifier “-58” was established to facilitate billing of staged or related surgical
procedures done during the postoperative period of the first procedure. This modifier is
not used to report the treatment of a problem that requires a return to the operating room.
The physician may need to indicate that the performance of a procedure or service during
the postoperative period was:
a. Planned prospectively or at the time of the original procedure;
b. More extensive than the original procedure; or
c. For therapy following a diagnostic surgical procedure.
These circumstances may be reported by adding modifier “-58” to the staged procedure.
A new postoperative period begins when the next procedure in the series is billed.
7. Unrelated Procedures or Visits During the Postoperative Period
Two CPT modifiers were established to simplify billing for visits and other procedures
which are furnished during the postoperative period of a surgical procedure, but which
are not included in the payment for the surgical procedure.
Modifier “-79”: Reports an unrelated procedure by the same physician during a
postoperative period. The physician may need to indicate that the performance of a
procedure or service during a postoperative period was unrelated to the original
procedure.
A new postoperative period begins when the unrelated procedure is billed.
Modifier “-24”: Reports an unrelated evaluation and management service by same
physician during a postoperative period. The physician may need to indicate that an
evaluation and management service was performed during the postoperative period of an
unrelated procedure. This circumstance is reported by adding the modifier “-24” to the
appropriate level of evaluation and management service.
Services submitted with the “-24” modifier must be sufficiently documented to establish
that the visit was unrelated to the surgery. A diagnosis code that clearly indicates that the
reason for the encounter was unrelated to the surgery is acceptable documentation.
A physician who is responsible for postoperative care and has reported and been paid
using modifier “-55” also uses modifier “-24” to report any unrelated visits.
8. Significant Evaluation and Management on the Day of a Procedure
Modifier “-25” is used to facilitate billing of evaluation and management services on the
day of a procedure for which separate payment may be made.
It is used to report a significant, separately identifiable evaluation and management
service by same physician on the day of a procedure. The physician may need to indicate
that on the day a procedure or service that is identified with a CPT code was performed,
the patient’s condition required a significant, separately identifiable evaluation and
management service above and beyond the usual preoperative and postoperative care
associated with the procedure or service that was performed. This circumstance may be
reported by adding the modifier “-25” to the appropriate level of evaluation and
management service.
Claims containing evaluation and management codes with modifier “-25” are not subject
to prepayment review except in the following situations:
• Effective January 1, 1995, all evaluation and management services provided on
the same day as inpatient dialysis are denied without review with the exception of
CPT Codes 99221-9223, 99251-99255, and 99238. These codes may be billed
with modifier “-25” and reviewed for possible allowance if the evaluation and
management service is unrelated to the treatment of ESRD and was not, and could
not, have been provided during the dialysis treatment;
• When preoperative critical care codes are being billed for within a global surgical
period; and
• When A/B MACs (B) have conducted a specific medical review process and
determined, after reviewing the data, that an individual or group have high
statistics in terms of the use of modifier “-25,” have done a case-by-case
review of the records to verify that the use of modifier “-25” was
inappropriate, and have educated the individual or group as to the proper use
of this modifier.
9. Critical Care
Critical care services provided during a global surgical period for a seriously injured
or burned patient are not considered related to a surgical procedure and may be paid
separately under the following circumstances.
Preoperative and postoperative critical care may be paid in addition to a global fee if:
• The patient is critically ill and requires the constant attendance of the
physician; and
• The critical care is above and beyond, and, in most instances, unrelated to the
specific anatomic injury or general surgical procedure performed.
Such patients are potentially unstable or have conditions that could pose a significant
threat to life or risk of prolonged impairment.
Modifier -24 (post-operative) or -25 (same day pre-operative) is used to indicate that
the critical care service is unrelated to the procedure.
10. Unusual Circumstances
Surgeries for which services performed are significantly greater than usually
required may be billed with the “-22” modifier added to the CPT code for the
procedure. Surgeries for which services performed are significantly less than usually
required may be billed with the “-52” modifier. The biller must provide:
• A concise statement about how the service differs from the usual; and
• An operative report with the claim.
Modifier “-22” should only be reported with procedure codes that have a global
period of 0, 10, or 90 days. There is no such restriction on the use of modifier “-52.”
B. Date(s) of Service
Physicians, who bill for the entire global surgical package or for only a portion of the
care, must enter the date on which the surgical procedure was performed in the
“From/To” date of service field. This will enable A/B MACs (B) to relate all appropriate
billings to the correct surgery. Physicians who share postoperative management with
another physician must submit additional information showing when they assumed and
relinquished responsibility for the postoperative care. If the physician who performed the
surgery relinquishes care at the time of discharge, he or she need only show the date of
surgery when billing with modifier “-54.”
However, if the surgeon also cares for the patient for some period following discharge,
the surgeon must show the date of surgery and the date on which postoperative care was
relinquished to another physician. The physician providing the remaining postoperative
care must show the date care was assumed. This information should be shown in Item 19
on the paper Form CMS-1500. See the related implementation guide for where to show
this information on the ASC X12 837 professional claim transaction format.
C. Care Provided in Different Payment Localities
If portions of the global period are provided in different payment localities, the services
should be billed to the A/B MAC (B) servicing each applicable payment locality. For
example, if the surgery is performed in one state and the postoperative care is provided in
another state, the surgery is billed with modifier “-54” to the A/B MAC (B) servicing the
payment locality where the surgery was performed and the postoperative care is billed
with modifier “-55” to the A/B MAC (B) servicing the payment locality where the
postoperative care was performed. This is true whether the services were performed by
the same physician/group or different physicians/groups.
D. Health Professional Shortage Area (HPSA) Payments for Services Which Are
Subject to the Global Surgery Rules
HPSA bonus payments may be made for global surgeries when the services are provided
in HPSAs. The following are guidelines for the appropriate billing procedures:
• If the entire global package is provided in a HPSA, physicians should bill for the
appropriate global surgical code with the applicable HPSA modifier.
• If only a portion of the global package is provided in a HPSA, the physician
should bill using a HPSA modifier for the portion which is provided in the HPSA.
EXAMPLE
The surgical portion of the global service is provided in a non-HPSA and the
postoperative portion is provided in a HPSA. The surgical portion should be billed with
the “-54” modifier and no HPSA modifier. The postoperative portion should be billed
with the “-55” modifier and the appropriate HPSA modifier. The 10 percent bonus will
be paid on the appropriate postoperative portion only. If a claim is submitted with a
global surgical code and a HPSA modifier, the A/B MAC (B) assumes that the entire
global service was provided in a HPSA in the absence of evidence otherwise.
NOTE: The sum of the payments made for the surgical and postoperative services
provided in different localities will not equal the global amount in either of the localities
because of geographic adjustments made through the Geographic Practice Cost Indices.
40.3 - Claims Review for Global Surgeries
(Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-
2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of
ICD-10)
A. Relationship to Correct Coding Initiative (CCI)
The CCI policy and computer edits allow A/B MACs (B) to detect instances of
fragmented billing for certain intra-operative services and other services furnished on the
same day as the surgery that are considered to be components of the surgical procedure
and, therefore, included in the global surgical fee. When both correct coding and global
surgery edits apply to the same claim, A/B MACs (B) first apply the correct coding edits,
then, apply the global surgery edits to the correctly coded services.
B. Prepayment Edits to Detect Separate Billing of Services Included in the Global
Package
In addition to the correct coding edits, A/B MACs (B) must be capable of detecting
certain other services included in the payment for a major or minor surgery or for an
endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the
following conditions:
• Preoperative services that are submitted on the same claim or on a subsequent
claim as a surgical procedure; or
• Same day or postoperative services that are submitted on the same claim or on a
subsequent claim as a surgical procedure or endoscopy;
and -
• Services that were furnished within the prescribed global period of the surgical
procedure;
• Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are
billed with modifier “-24” but without the required documentation; and
• Services that are billed with the same provider or group number as the surgical
procedure or endoscopy. Also, edit for any visits billed separately during the
postoperative period without modifier “-24” by a physician who billed for the
postoperative care only with modifier “-55.”
A/B MACs (B) use the following evaluation and management codes in establishing edits
for visits included in the global package. CPT codes 99241, 99242, 99243, 99244,
99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275
have been transferred from the excluded category and are now included in the global
surgery edits.
Evaluation and Management Codes for A/B MAC (B) Edits
92012
92014
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99261
99262
99263
99271
99272
99273
99274
99275
99291
99292
99301
99302
99303
99311
99312
99313
99315
99316
99331
99332
99333
99347
99348
99349
99350
99374
99375
99377
99378
NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the
preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used
to indicate that the critical care was unrelated to the specific anatomic injury or general
surgical procedure performed.
If a surgeon is admitting a patient to a nursing facility for a condition not related to the
global surgical procedure, the physician should bill for the nursing facility admission and
care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a
patient to a nursing facility and the patient’s admission to that facility relates to the global
surgical procedure, the nursing facility admission and any services related to the global
surgical procedure are included in the global surgery fee.
C. Exclusions from Prepayment Edits
A/B MACs (B) exclude the following services from the prepayment audit process and
allow separate payment if all usual requirements are met:
Services listed in §40.1.B; and
Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.”
Exceptions
See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required
for modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935,
90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services.
Exclude the following codes from the prepayment edits required in §40.3.B.
92002
92004
99201
99202
99203
99204
99205
99281
99282
99283
99284
99285
99321
99322
99323
99341
99342
99343
99344
99345
40.4 - Adjudication of Claims for Global Surgeries
(Rev. 3721, Issued: 02-24-17, Effective: 05-25-17, Implementation: 05-25-17)
A. Fragmented Billing of Services Included in the Global Package
Since the Medicare fee schedule amount for surgical procedures includes all services that
are part of the global surgery package, A/B MACs (B) do not pay more than that amount
when a bill is fragmented. When total charges for fragmented services exceed the global
fee, process the claim as a fee schedule reduction (except where stated policies, e.g., the
surgeon performs only the surgery and a physician other than the surgeon provides
preoperative and postoperative inpatient care, result in payment that is higher than the
global surgery allowed amount). A/B MACs (B) do not attribute such reductions to
medical review savings except where the usual medical review process results in
recoding of a service, and the recoded service is included in the global surgery package.
The maximum a nonparticipating physician may bill a beneficiary on an unassigned
claim for services included in the global surgery package is the limiting charge for the
surgical procedure.
In addition, the limitation of liability provision (§1879 of the Act) does not apply to these
determinations since they are fee schedule reductions, not denials based upon medical
necessity or custodial care.
Claims for surgeries billed with a “-22” or “-52” modifier, are priced by individual
consideration if the statement and documentation required by §40.2.A.10 are included. If
the statement and documentation are not submitted with the claim, pricing for “-22” is it
the fee schedule rate for the same surgery submitted without the “-22” modifier. Pricing
for “-52” is not done without the required documentation.
Separate payment is allowed for visits and procedures billed with modifier “-78,” “-79,”
“-24,” “-25,” “-57,” or “-58.” Modifier “-24” must be accompanied by sufficient
documentation that the visit is unrelated to the surgery. Also, when used with the critical
care codes, modifiers “-24” and “-25” must be accompanied by documentation that the
critical care was unrelated to the specific anatomic injury or general surgical procedure
performed.
A/B MACs (B) do not allow separate payment for evaluation and management services
furnished on the same day or during the postoperative period of a surgery if the services
are billed without modifier “-24,” “-25,” or “-57.” These services should be denied. A/B
MACs (B) do not allow separate payment for visits during the postoperative period that
are billed with the modifier “-24” but without sufficient documentation. These services
should also be denied. Modifier “-24” is intended for use with services that are
absolutely unrelated to the surgery. It is not to be used for the medical management of a
patient by the surgeon following surgery. Recognize modifier “-24” only for care
following discharge unless:
• The care is for immunotherapy management furnished by the transplant surgeon;
• The care is for critical care for a burn or trauma patient; or
• The documentation demonstrates that the visit occurred during a subsequent
hospitalization and the diagnosis supports the fact that it is unrelated to the
original surgery.
A/B MACs (B) do not allow separate payment for an additional procedure(s) with a
global surgery fee period if furnished during the postoperative period of a prior procedure
and if billed without modifier “-58,” “-78,” or “-79.” These services should be denied.
Codes with the global surgery indicator of “XXX” in the MFSDB can be paid separately
without a modifier.
B. Claims From Physicians Who Furnish Less Than the Global Package (Split
Global Care)
For surgeries performed January 1, 1992, and later, that are billed with either modifier
“-54” or “-55,” A/B MACs (B) pay the appropriate percentage of the fee schedule
payment. Fields 17-19 of the MFSDB list the appropriate percentages for pre-, intra-,
and postoperative care of the total RVUs for major surgical procedures and for minor
surgeries with a postoperative period of 10 days. The intra-operative percentage includes
postoperative hospital visits.
Procedures with a “000” entry in Field 16 have an entry of “0.0000” in Fields 17-19.
Split global care does not apply to these procedures.
A/B MACs (B) multiply the fee schedule amount (Field 34 or Field 35 of the MFSDB)
by this percentage and round to the nearest cent. Assume that a physician who bills with
a “-54” modifier has provided both preoperative, intra-operative and postoperative
hospital services. Pay this physician the combined preoperative and intra-operative
portions of the fee schedule payment amount.
Where more than one physician bills for the postoperative care, A/B MACs (B) apportion
the postoperative percentage according to the number of days each physician was
responsible for the patient’s care by dividing the postoperative allowed amount by the
number of post-op days and that amount is multiplied by the number of days each
physician saw the patient.
EXAMPLE
Dr. Jones bills for procedure “42145-54” performed on March 1 and states that he cared
for the patient through April 29. Dr. Smith bills for procedure “42145-55” and states
that she assumed care of the patient on April 30. The percentage of the total fee amount
for the postoperative care for this procedure is determined to be 17 percent and the length
of the global period is 90 days. Since Dr. Jones provided postoperative care for the first
60 days, he will receive 66 2/3 percent of the total fee of 17 percent since 60/90 = .6666.
Dr. Smith’s 30 days of service entitle her to 30/90 or .3333 of the fee.
6666 x .17 = .11333 or 11.3%; and
3338 x .17 = .057 or 5.7%.
Thus, Dr. Jones will be paid at a rate of 11.3 percent (66.7 percent of 17 percent). Dr.
Smith will be paid at a rate of 5.7 percent (33.3 percent of 17 percent).
C. Payment for Return Trips to the Operating Room for Treatment of
Complications
When a CPT code billed with modifier “-78” describes the services involving a return trip
to the operating room to deal with complications, A/B MACs (B) pay the value of the
intra-operative services of the code that describes the treatment of the complications.
Refer to Field 18 of the MFSDB to determine the percentage of the global package for
the intra-operative services. The fee schedule amount (Field 34 or 35 of the MFSDB) is
multiplied by this percentage and rounded to the nearest cent.
When a procedure with a “000” global period is billed with a modifier “-78,”
representing a return trip to the operating room to deal with complications, A/B MACs
(B) pay the full value for the procedure, since these codes have no pre-, post-, or intra-
operative values.
When an unlisted procedure is billed because no code exists to describe the treatment for
complications, A/B MACs (B) base payment on a maximum of 50 percent of the value of
the intra-operative services originally performed. If multiple surgeries were originally
performed, A/B MACs (B) base payment on no more than 50 percent of the value of the
intra-operative services of the surgery for which the complications occurred. They
multiply the fee schedule amount for the original surgery (Field 34 or 35) by the intra-
operative percentage for the procedure (Field 18), and then multiply that figure by 50
percent to obtain the maximum payment amount.
[.50 X (fee schedule amount x intra-operative percentage)]. Round to the nearest
cent.
If additional procedures are performed during the same operative session as the original
surgery to treat complications which occurred during the original surgery, A/B MACs (B)
pay the additional procedures as multiple surgeries. Only surgeries that require a return
to the operating room are paid under the complications rules.
If the patient is returned to the operating room after the initial operative session, but on
the same day as the original surgery for one or more additional procedures as a result of
complications from the original surgery, the complications rules apply to each procedure
required to treat the complications from the original surgery. The multiple surgery rules
would not also apply.
If the patient is returned to the operating room during the postoperative period of the
original surgery, not on the same day of the original surgery, for multiple procedures that
are required as a result of complications from the original surgery, the complications
rules would apply. The multiple surgery rules would also not apply.
If the patient is returned to the operating room during the postoperative period of the
original surgery, not on the same day of the original surgery, for bilateral procedures that
are required as a result of complications from the original surgery, the complication rules
would apply. The bilateral rules would not apply.
D. MSN and Remittance Messages
When A/B MACs (B) deny separate payment for a visit because it is included in the
global package, include one of the following statements on the MSN to the beneficiary
and the remittance notice sent to the physician.
1. Messages for Fragmented Billing by a Single Physician
When a single physician bills separately for services included in the global surgical
package which has already been billed:
The following reflects the remittance advice messages and associated codes that
will appear when rejecting/denying claims under this policy. This CARC/RARC
combination is compliant with CAQH CORE Business Scenario 4.
Group Code: CO
CARC: 97
RARC: N/A
MSN: 23.1
When a single physician bills separately for services included in the global surgical
package which has not yet been billed/adjudicated:
The following reflects the remittance advice messages and associated codes that
will appear when rejecting/denying claims under this policy. This CARC/RARC
combination is compliant with CAQH CORE Business Scenario 3.
Group Code: CO
CARC: B15
RARC: N/A
MSN: 23.1
2. Messages for Global Packages Split Between Two or More Physicians
When a physician furnishes only the pre- and intra-operative services, but bills for the
entire package:
The following reflects the remittance advice messages and associated codes that
will appea