Search This Blog

New Updates for COVID-19 Lab Codes

Modifier QW

The Medicare and Medicaid only pay for laboratory tests performed in certified facilities, each claim for a HCPCS code that is considered a CLIA laboratory test is currently edited at the CLIA certificate level. 

To be recognized as a test that can be performed in a facility having a CLIA certificate of waiver for listed below CPT codes and the modifier QW must be added.

The CMS released updates for adding modifier QW for COVID-19 lab codes with effective date of service.

  • The Medicare contractor shall permit the use of code 87636 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after October 6, 2020 and effective from July 1, 2021
  • The Medicare contractor shall permit the use of code 87428 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after November 10, 2020.

  • The Medicare contractor shall permit the use of code 87811 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after October 6, 2020.

    • The Medicare contractor shall permit the use of code 87635 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after March 20, 2020.

    New Codes Effective November 10, 2020

    • 87428 - Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARSCoV-2 [COVID-19]) and influenza virus types A and B

    New Codes Effective October 6, 2020 

    The listed new codes are on the national HCPCS file with an effective date of October 6, 2020 and do not need to be manually added to the HCPCS files by the MACs. 

    However, these new codes are contractor priced (where applicable) until they are nationally priced and undergoes the CLFS annual payment determination process in accordance with the Social Security Act § 1833(h)(8), § 1834A(c) and § 1834(A)(f).

    • 87636 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique.
    • 87637 - Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique
    • 87811 -  Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).



    CCM - Complex Chronic Care Management

    CPT Codes

    99487 - Complex chronic care management services can be billed with following criteria are met

    • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.
    • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
    • Establishment or substantial revision of a comprehensive care plan
    • Moderate or high complexity medical decision making

    Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not reported separately

    99489 - Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). 

    Report 99489 in conjunction with 99487. 

    Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month.

    Guidelines

    60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

    This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both).

    Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately

    Eligible Provider's

    • Physicians and the following non-physician practitioners may bill CCM services,
    • Certified Nurse Midwives
    • Clinical Nurse Specialists
    • Nurse Practitioners
    • Physician Assistants

    The CCM service is not within the scope of practice of limited-license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.

    CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner)

    A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements,

    • Problem list
    • Expected outcome and prognosis
    • Measurable treatment goals
    • Symptom management
    • Planned interventions and identification of the individuals responsible for each intervention
    • Medication management
    • Community/social services ordered
    • A description of how services of agencies and specialists outside the practice are directed/coordinated
    • Schedule for periodic review and, when applicable, revision of the care plan

    Initiating Visit 

    • Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visits not required), for new patients or patients not seen within 1 year prior to the commencement of CCM services.

    Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506

    G0506 - Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service].

    G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.

    Note: The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month. Do not report 99491 in the same calendar month as 99487, 99489, 99490.


    Return to CCM Billing

    Chronic Care Management (CCM) Guidelines

    The Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions from 2015

    Guidelines

    • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
    • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
    • Comprehensive care plan established, implemented, revised, or monitored
    • Only one practitioner may be paid for CCM services for a given calendar month.
    • This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both).
    • CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM.
    • The CCM service is not within the scope of practice of limited-license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.
    • CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner),

     

    CPT Codes

     

    99490 - Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month,

    99491 - Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes per calendar month,

     

    Eligible Provider's

     

    • Physicians and the following non-physician practitioners may bill CCM services,
      • Certified Nurse Midwives
      • Clinical Nurse Specialists
      • Nurse Practitioners
      • Physician Assistants
     
    Examples of chronic conditions include, but are not limited to, the following,
    • Alzheimer’s disease and related dementia
    • Arthritis (osteoarthritis and rheumatoid)
    • Asthma
    • Atrial fibrillation
    • Autism spectrum disorders
    • Cancer
    • Cardiovascular Disease
    • Chronic Obstructive Pulmonary Disease
    • Depression
    • Diabetes
    • Hypertension
    • Infectious diseases such as HIV/AIDS
     
    Note:

    CPT code 99491 includes only time that is spent personally by the billing practitioner. Clinical staff time is not counted towards the required time threshold for reporting this code.

    The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month. Do not report 99491 in the same calendar month as 99487, 99489, 99490.


    BURN ICD Guidelines

    Definition of Burn

    • The burn is tissue damage with the partial or complete destruction of the skin caused by heat, chemicals, electricity, sunlight, or nuclear radiation. 
    • Scalds from hot liquids and steam, building fires, and flammable liquids and gases are the most common causes of burns. Inhalation injury, another type of burn, results from breathing smoke.

    Burn Types

    • Thermal burns are caused by an external heat source such as fire or hot liquids in direct contact with the skin, causing tissue cell death or charring.
    • Electrical burns happen when the body makes contact with an electric current. Electrical burns can be more extensive than what is seen externally, often affecting internal tissues and muscles.
    • Radiation dermatitis is a type of dermatitis resulting from exposure of the skin, eyes, or internal organs to types of radiation. Causes include exposure from sources such as Cobalt therapy, fluoroscopy, welding arcs, sun exposure, and tanning bed lights.
    • Corrosion's are chemical burns due to contact with internal or external body parts caused by strong acids such as bleach and battery fluid, or strong bases (alkalis) such as ammonia, detergents, or solvents.

    Degrees of Burns

    Burn severity is classified based on the depth of the burn. There are six degrees of burns,
    • First-degree burns damage the outer layer (epidermis) of the skin. These burns are usually dry, red (erythematous), and painful and usually heal on their own within a week. A common example is a sunburn.
    • Second-degree burns indicate blistering with damage extending beyond the epidermis partially into the layer beneath it (dermis). When severe, these burns might necessitate a skin graft — natural or artificial skin to cover and protect the body while it heals — and they may leave a scar
    • Third-degree burns indicate full-thickness tissue loss with damage or complete destruction of both layers of skin (including hair follicles, oil glands, and sweat glands). These burns always require skin grafts
    • Fourth-degree burns extend into fat.
    • Fifth-degree burns extend into the muscle
    • Sixth-degree burns extend damage down to the bone
    Many patients suffer from burns in multiple anatomical locations. When coding these cases,

    Assign a separate code for each location with a burn.

    • If a patient has multiple burns on the same anatomical site, select the code that reflects the most severe burn for that location.
    • Sequence the codes in order of severity, with the most severe burn listed first.
    • When a patient has both internal and external burns/corrosion's, the circumstances of admission govern the selection of the principal diagnosis (i.e., first-listed diagnosis).
    • When a patient is admitted for burn injuries and other related conditions, such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal diagnosis.

    Code Using the Rule of Nines

    ICD-10 burn codes are reported by body location, depth, extent, and external cause, including the agent or cause of the corrosion, as well as laterality and encounter. To code burn cases correctly, specify the site, severity, extent, and external cause.

    You need at least three codes to properly report burn diagnoses,

    First-listed code(s): Site and severity (from categories T20-T25)

    • Your first-listed code will be a combination code that reports both the site and severity of the injury. The site refers to the anatomical location that is affected by the burn or corrosion. 
    • Code descriptions in the T20-T28 range first define a general part or section of the human body.
    • The fourth character for each category identifies the severity (except categories T26-T28). 
    • Using the layers of the skin, the severity of a burn is identified by degree.
    • The fifth character enables you to report additional details regarding the anatomical site of the burn.
    • The sixth character represents laterality.

    Next-listed code: Extent (from code category T31/T32)

    • Burns and corrosions are classified according to the extent or percentage of the body surface involved.
    • Total body surface area (TBSA) involved is reported using a code from T31 for a burn or T32 for corrosion, based on the classic “rule of nines,”.
    • The rule of nines for adult patients assigns 1 percent of TBSA to the genitalia and multiples of 9 percent to other body areas (9 percent for the head, 9 percent per arm, 18 percent per leg, etc.).
    • A modified rule of nines is applied for infants to account for their relatively larger head (18 percent) and smaller legs (14 percent, each).
    • The required fourth character identifies the percentage of the patient’s entire body affected by burns.
    • The fifth character identifies the percentage of the patient’s body suffering from third-degree burns or corrosion's only.

    Additional code(s): External cause code(s)

    • ICD-10-CM guidelines recommend reporting appropriate external cause codes for burn patients. Not all payers accept these codes, however.
    • External cause – To identify the source, place, and intent of the burn.
    • Agent – To identify the chemical substance of the corrosion.
    • Determining a CPT code for burn treatment requires documentation of the degree of the burn and the percentage of body area affected. Documenting what is done during the visit is important because burn coding can be used for a dressing change or debridement.

    Note: 

    • Burn treatment codes can be used in addition to an office visit; however, the office visit must be medically necessary and modifier 25 Significant, separately identifiable evaluation and management service by the same physician other qualified health care professional on the same day of the procedure or other service must be appended to the office visit. 

    MDM - Selection of Risk

    Risk Table

    The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration.

    For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. 

    Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. 

    Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). 

    For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. 

    The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.

    Morbidity

    A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment. 

    Social determinants of health 

    Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.

    Surgery (minor or major, elective, emergency, procedure or patient risk):  

    Surgery–Minor or Major

    The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. 

    Surgery–Elective or Emergency

    Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. 

    An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization.

    Both elective and emergent procedures may be minor or major procedures.

    Surgery–Risk Factors, Patient or Procedure

    Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.

    Drug therapy requiring intensive monitoring for toxicity

    A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. 

    The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.

    The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. 

    Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. 

    The monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. 

    The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. 

    Examples may include monitoring for cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuretics. 

    Examples of monitoring that do not qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic effect (even if unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the threshold. 

    Return to E/M Guidelines for Office/Outpatient 2021

    MDM - Selection of Data

    Data and Analyzed

    The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. 

    Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. 

    In the case of a recurring ordereach new result may be counted in the encounter in which it is analyzed. 

    For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed. 

    Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter. 

    Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM.

    Test

    Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. 

    The differentiation between single or multiple unique tests is defined in accordance with the CPT code set. For the purposes of data reviewed and analyzed, pulse oximetry is not a test

    Unique Source

    A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test.

    Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes.

    For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

    Combination of Data Elements

    A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. 

    It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.

    External

    External records, communications and/or test results are from an external physician, other qualified health care professional, facility, or health care organization. 

    External physician or other qualified health care professional

    An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or sub-specialty. 

    This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.

    Discussion

    Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. 

    The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).

    Independent historian(s)

    An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. 

    In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. 

    The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.

    Independent interpretation

    The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient. 

    A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.

    Appropriate source

    For the purpose of the discussion of management data element Levels of Medical Decision Making), an appropriate source includes professionals who are not health care professionals but may be involved in the management of the patient (eg, lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.

    MDM - Selection of Diagnosis

    Number and Complexity of Problems Addressed at the Encounter  

    One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter. 

    Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. 

    The Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. 

    The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. 

    Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

    Definitions for the elements of MDM

    Problem

    A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter

    Problem addressed

    A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. 

    This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/ surrogate choice. 

    Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. 

    Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

    Minimal problem

    A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211). 

    Self-limited or minor problem

    A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

    Stable, chronic illness

    A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). 

    “Stable” for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. 

    For example, in a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic, The risk of morbidity without treatment is significant. Examples may include well-controlled hypertension, noninsulin- dependent diabetes, cataract, or benign prostatic hyperplasia.

    Acute, uncomplicated illness or injury

    A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. 

    A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. 

    Examples may include cystitis, allergic rhinitis, or a simple sprain. 

    Chronic illness with exacerbation, progression, or side effects of treatment

    A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care. 

    Undiagnosed new problem with uncertain prognosis

    A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.

    Acute illness with systemic symptoms

    An illness that causes systemic symptoms and has a high risk of morbidity without treatment. 

    For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. 

    Systemic symptoms may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

    Acute, complicated injury

    An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness. 

    Chronic illness with severe exacerbation, progression, or side effects of treatment

    The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care. 

    Acute or chronic illness or injury that poses a threat to life or bodily function

    An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. 

    Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurological status.

    Details and Definition of MDM 2021

    Number and Complexity of Problems Addressed at the Encounter  

    One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter. 

    Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. 

    The Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. 

    The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. 

    Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

    Definitions for the elements of MDM

    Problem

    A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter

    Problem addressed

    A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. 

    This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/ surrogate choice. 

    Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. 

    Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

    Minimal problem

    A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211). 

    Self-limited or minor problem

    A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

    Stable, chronic illness

    A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). 

    “Stable” for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. 

    For example, in a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic, The risk of morbidity without treatment is significant. Examples may include well-controlled hypertension, noninsulin- dependent diabetes, cataract, or benign prostatic hyperplasia.

    Acute, uncomplicated illness or injury

    A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. 

    A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. 

    Examples may include cystitis, allergic rhinitis, or a simple sprain. 

    Chronic illness with exacerbation, progression, or side effects of treatment

    A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care. 

    Undiagnosed new problem with uncertain prognosis

    A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.

    Acute illness with systemic symptoms

    An illness that causes systemic symptoms and has a high risk of morbidity without treatment. 

    For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. 

    Systemic symptoms may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

    Acute, complicated injury

    An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness. 

    Chronic illness with severe exacerbation, progression, or side effects of treatment

    The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care. 

    Acute or chronic illness or injury that poses a threat to life or bodily function

    An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. 

    Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status.

    Data and Analyzed

    The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. 

    Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. 

    In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. 

    For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed. 

    Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter. 

    Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM.

    Test

    Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. 

    The differentiation between single or multiple unique tests is defined in accordance with the CPT code set. For the purposes of data reviewed and analyzed, pulse oximetry is not a test

    Unique Source

    A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test.

    Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes.

    For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

    Combination of Data Elements

    A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. 

    It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.

    External

    External records, communications and/or test results are from an external physician, other qualified health care professional, facility, or health care organization. 

    External physician or other qualified health care professional

    An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty. 

    This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.

    Discussion

    Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. 

    The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).

    Independent historian(s)

    An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. 

    In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. 

    The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.

    Independent interpretation

    The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient. 

    A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.

    Appropriate source

    For the purpose of the discussion of management data element Levels of Medical Decision Making), an appropriate source includes professionals who are not health care professionals but may be involved in the management of the patient (eg, lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.

    Risk

    The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration.

    For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. 

    Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. 

    Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). 

    For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. 

    The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.

    Morbidity

    A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment. 

    Social determinants of health 

    Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.

    Surgery (minor or major, elective, emergency, procedure or patient risk):  

    Surgery–Minor or Major

    The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. 

    Surgery–Elective or Emergency

    Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. 

    An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization.

    Both elective and emergent procedures may be minor or major procedures.

    Surgery–Risk Factors, Patient or Procedure

    Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.

    Drug therapy requiring intensive monitoring for toxicity

    A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. 

    The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.

    The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. 

    Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. 

    The monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. 

    The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. 

    Examples may include monitoring for cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. 

    Examples of monitoring that do not qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic effect (even if unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the threshold. 

    Return to E/M Guidelines for Office/Outpatient 2021


    E/M Guidelines for Office/Outpatient 2021

    E/M Guidelines for Office/Outpatient History and Exam

    The 2021 E&M Guidelines for Office or Other Outpatient E/M Services will help you understand the revised E/M codes.

    The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.”

    The “Medically appropriate” means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service.

    Remember that code selection does not depend on the level of history or exam.

    The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information.

    MEDICAL DECISION ON MAKING GUIDELINES

    The code selection will be either total encounter time or MDM to select the level of office or other outpatient E/M in 2021, 

    In the 2021 MDM guidelines, CPT states that MDM “includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.” Three elements define MDM for office/outpatient visits in 2021, and they are similar but not identical to the 2020 elements

     

    Table Row 1 Diagnosis

     

    The number and complexity of the problem or problems the provider addresses during the E/M encounter.
    • In 2020, the guidelines instead referred to “the number of possible diagnoses and/or the number of management options.”

    Table Row 2 Data

     

    The amount and/or complexity of data to be reviewed and analyzed.” The 2021 guidelines list three categories for data: 
    1. Tests, documents, orders, or independent historians, 
    2. Independent test interpretation, and 
    3. Discussion of management or test interpretation with external providers or appropriate sources. 
    The latter term refers to non-healthcare, non-family sources involved in patient management, like a parole officer or case manager.
    • The 2020 MDM guidelines also included the amount and/or complexity of medical records, test, and other information involved, but the 2021 guidelines expand the section significantly

     

    Table Row 3 Risk

     

    The risk of complications and/or morbidity or mortality of patient management decisions made at the visit.” 

    The 2021 guidelines make it clear that options considered, but not selected, are still a factor for this element, specifically after “shared” MDM with the patient, family, or both. Examples include deciding against hospitalization for a psychiatric patient with sufficient support for outpatient care or choosing palliative care for a patient with advanced dementia and an acute condition.
    • The 2020 MDM guidelines included comparable wording, but they did not include the reference to shared MDM or the examples found in the 2021 guidelines.

    MDM - Medical Decision Making Table

    The 2021 MDM table in the CPT E/M guidelines has three main columns with the final column divided into three additional columns
    1. Code
    2. Level of MDM (Based on 2 out of 3 Elements of MDM)
    3. Elements of Medical Decision Making
      • Number and Complexity of Problems Addressed at the Encounter
      • Amount and/or Complexity of Data to be Reviewed and Analyzed
      • Risk of Complications and/or Morbidity or Mortality of Patient Management


    Additional Information About Modifiers

    Sequencing of modifiers 

    How can that be if the modifiers used were accurate? 

    There is an order to reporting modifiers and there are three categories that modifier usage fall under: 

    1. Pricing 

    • Pricing modifiers are always sequenced “before” payment modifiers and/or location modifiers.  
    • The only exception to this rule is when a global surgery package is involved. 
    • For example, you would code modifier 58 first and modifier 82 second in a global surgery. 
    • A few examples of pricing modifiers are: 22, 26, 50, 52, 53, 62, 80, and P1-P6.  

    2. Payment  

    • Payment modifiers alert the insurance carrier that there is a special situation within the claim 
    • Some examples of payment modifiers would be: 24, 25, 51, 57, 58, 59, 76, and 78. 

    3. Location 

    • Examples of location modifiers are: E1-E4, FA, F1-F9, LC, LD, LT, RT, RC, TA, and T1-T9. 
    The general order of sequencing modifiers is (1) pricing (2) payment (3) location. Location modifiers, in all coding situations, are coded “last”. 

    If you code two pricing modifiers that include either a professional or technical component (26 or TC), always use the 26 or TC first, followed by the second pricing modifier. 

    If you have two payment modifiers, for example 51 and 59, enter 59 first and 51 second. If 51 and 78 are the required modifiers, you would enter 78 in the first position. 

    Additional Information 

    000 = Endoscopic or minor procedure with related preoperative and postoperative relative value units on the day of the procedure only, included in the fee schedule payment amount 

    010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative values during a 10-day postoperative period included in the fee schedule amount 

    090 = Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule payment amount 

    MMM = Maternity codes. The usual global period does not apply. 

    XXX = Global concept does not apply 

    YYY = Palmetto GBA will determine whether the global concept applies and establish a postoperative period, if appropriate 

    ZZZ = Code is related to another service ("add-on" code) and is always included in the global period of the other service 


    Check Modifier  78 & 79

    Modifier 78 and 79

    Modifier 78 

    “Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period 

    Modifier 79

    “Unrelated procedure or service by the same physician during a post-operative 

    Example - Modifier 78 

    The Dual chamber Pacemaker (CPT 33208) was implanted on Dec 26th and during the post-operative periods, the patients feel uncomfortable due to pain, hence the provider examined and confirmed the Atrial lead and or Ventricular lead is dislodged, hence provider performed “Repositioning of right atrial or right ventricular lead” on Jan 10th.  

    For mentioned above scenarios, the claim must be submitted with modifier 78, since this procedure performed within 90 days. CPT 33215 – 78 

    Example - Modifier 79 

    The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.  

    Provider performs right toe amputation on May 24, 2015 and a left foot amputation On June 25, 2015, surgery was medically necessary within this 90-day global period 

    • 5/24/15 Amputation big toe, RT  28820 TA 
    • 6/25/15 Amputation foot, LT  28800 79 

     

    Click here for Additional Information

    Usage of Modifier 24 and 59

    Modifier 24 

    An Unrelated evaluation and management service performed by the same physician or other qualified health care professional during a post-operative period use modifier 24 for E/M Services. (Never to a procedure) 

    Modifier 24 is applied to two code sets, 

    • E/M (Evaluation and management) services (99201-99499). 
    • General ophthalmological services (92002-92014), which are eye examination codes. 

    Appropriate Use of Modifier 24 

    • An unrelated E/M service is performed beginning the day after the procedure, by the same physician, during the 10 or 90-day post-operative period.  
    • Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.
    • Unrelated critical care performed by the same physician during the post-operative period. 

    Inappropriate Use 

    Do not use Modifier 24 when, 

    • The E/M is for a surgical complication or infection. This treatment is part of the surgery package. 
    • The service is removal of sutures or other wound treatment. This treatment is part of the surgery package. 
    • The surgeon admits a patient to a skilled nursing facility for a condition related to the surgery. 
    • The medical record documentation clearly indicates the E/M is related to the surgery. 
    • Outside of the post-op period of a procedure. 
    • Services are rendered on the same day as the procedure 
    • Reporting exams performed for routine postoperative care. 
    • Reporting surgical procedures, labs, x-rays, or supply codes. 

    Example 1 

    A Cardiologist was implanted Pacemaker Implantation on Dec. 26th due to complete Heart Block, and the patient returns with Chest pain and diagnosed as angina on Jan. 10th.  

    The Jan. 10th visit is separately reportable with appropriate level of service codes with modifier 24, since it’s unrelated to the original procedure performed Dec 26th.  

    Modifier 59 – X (E, P, S, U) 

    “Distinct Procedural Service” - Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. 

    The Centers for Medicare & Medicaid Services (CMS) established four (4) new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported. 

    XE – “Separate encounter" A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service. 

    XS – “Separate Structure" A service that is distinct because it was performed on a separate organ/structure.

    XP – “Separate Practitioner" A service that is distinct because it was performed by a different practitioner.

    XU – “Unusual Non-Overlapping Service", the use of a service that is distinct because it does not overlap usual components of the main service.

    • Modifier 59 should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes.
    • The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. 
    • Modifier 59 should not be appended to an E/M service. 

    Examples: 

    Modifier XU 

    • If Cardiac Cath (93454 to 93461) & PCI (92920 to 92943) procedure performed together during the same visit. We can bill with modifier XU for Cardiac Cath Procedures (column 2 codes). 

    Modifier XE 

    • If the mentioned above procedures are performed in two different encounters, the claim must be billed with modifier XE for Cardiac Cath CPT codes. 

    Modifier XP 

    • For mentioned above procedures are performed two different providers’, bill the claim with modifier XP. 

    Modifier XS 

    • For same procedure performed in two different location and or anatomical site we can use modifier XS for same CPT code if there are no anatomical site modifiers applicable, (Like RT & LT) 
    • Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550- XS). 

    Note: Medicaid & Medicaid HMO’s would not be accepted Anatomical site modifiers and or HCPCS modifier, so please use modifier 59 instead of X (E, P, S, U) and or not required HCPCS modifier, like RT, LT, RC, LC, LD and etc...) 

    Modifier Indicator: 

    • 0: not allowed (ie, modifier -59 is not allowed under any circumstances; the code pair will not be paid separately); 
    • 1: allowed (ie, coders may be able to append modifier -59 to differentiate between services provided; separate payment will be allowed); or 
    • 9: not applicable (ie, no modifier is necessary, as the edit is inactive as of the posted date; services may be separately billable). 

     

    ICD 10 CM Updates

    Guidelines for billing CPT G2211

    About CPT G2211 & Objectives Effective from January 1, 2024, the Centers for Medicare and Medicaid Services (CMS) began reimbursing for ...