Answers to some of the most common coding questions we hear. If you still have questions, we’d love to help.
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This is perfectly fine, as long as all other reviewed systems were, in fact, negative and a complete ROS is medically necessary.
It depends on whether the service is classified as a split/shared or “incident to.” If the service is split/shared between a physician and a non-physician practitioner (NPP) and the “incident to” requirements aren’t met, the service must be billed under the NPP’s national provider identifier (NPI). The service is considered “incident to” if the requirements are met and the patient is established.
A split/shared evaluation and management (E/M) visit is defined by Medicare 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 large portion of an E/M visit involves the history, examination or medical decision making components. The physician and NPP must be in the same practice or have the same employer.
If you only include the physician’s signature on the visit, Medicare will assume that the physician personally performed the visit. Notes recorded in the medical record by another provider, whether typed or handwritten, are considered relevant documentation of the visit. All documentation must include the date and a legible signature.
Not necessarily. Although critical care may be delivered in these situations, it’s not a requirement for providing critical care service. Critical care is defined as “the direct delivery by a physician’s medical care for a critically ill or critically injured patient… (which) 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.”
Per the Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) publication 100-04, Chapter 12, Section 30.6.12, critical care services “encompass both treatments of ‘vital organ failure’ and ‘prevention of further life-threatening deterioration of the patient’s condition.’ 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).”
Even if care is given in a moment of crisis, if a provider is called to a patient whose health may be in jeopardy or to avoid impairment/dysfunction, these scenarios alone don’t meet the requirements for providing critical care.
The bottom line: “Vital organ failure” and “prevention of further life threatening deterioration” must be universally evident. However, “moments of crisis” can be escalated into critical care if these points are exhibited. Documentation must indicate the level/type of treatment required.
*Note: critical care of less than 30 minutes on a given calendar date isn’t reported separately using the critical care codes. This service should be reported using another appropriate evaluation and management code, such as subsequent hospital care.”
When a patient’s care escalates from an emergency visit to admittance into the hospital, the patient does not pay for both services. Additionally, a patient would not pay for an emergency visit with the same physician on the same day.
All services provided by the physician after being admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility) are considered part of the initial hospital care when performed on the same date.
The incident to provisions does not apply to hospital settings. See below for exceptions.
The only exception is when the physician establishes an office within a nursing home or other institution. Where a physician establishes an office within a nursing home or other institution, coverage of services and supplies used in the office must be determined in accordance with the “incident to a physician’s professional service” provision as in any physician’s office.
A physician’s office within an institution must be confined to a separately identified part of the facility which is used solely as the physician’s office and can’t be construed to extend throughout the entire institution. Thus, services performed outside the office area would be subject to the coverage rules applicable to services furnished outside the office setting.
Current Procedural Terminology® (CPT®) code 99024 is a bundled code within Medicare, meaning payment is always bundled into the payment of other services. However, for data collection purposes, some providers are required to bill for this code.
*Florida providers only: For dates of services on and after July 1, 2017, you would bill CPT® code 99024 for all postoperative follow-up visits if you practice in a group of ten or more practitioners and provide global services under one of the required surgical procedure codes. All other practitioners are encouraged, but not required, to report post-operative visits using CPT® code 99024. Although you’re required to bill code 99024, you will not receive reimbursement. The code is still considered a bundled code for payment purposes; you’re being required to report the code for data collection purposes only.
*Puerto Rico and U.S. Virgin Islands providers: If the service is being provided for post-operative care, it is not necessary to bill the visit unless you are seeking a denial for a secondary insurance.”
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