Telehealth Updates 2023

The CMS released new updates in January 2023 for the medicare fee schedule summary for telehealth services. 

The updates are effective from January 1, 2023 and the implemented date is January 3, 2023. 

The major changes are Medicare Physician Fee Schedule and mentioned following four category and every providers, coders and billing staff knows this guidelines and changes.

• Telehealth originating site facility fee payment amount
• Expansion of coverage for colorectal cancer screening
• Coverage of Audiology services
• Other covered services

The Medicare will continue to pay the telehealth service payment at same rate in person outpatient fee rate through out end of the 2023, And there is no changes and or decrease the fee rate. 

And also, the Medicare will continuously paying the audio visit service CPT code 99441, 99442 & 99443 at the same rate of outpatient established office rate for the length of service/time spends with the patient.

For Medicare patients, the provider would continue to bill the telehealth claims with the place of services indicate that the service bill under In-Person visit. And the claims must be billed with modifier 95 to indicate the service is performed in telehealth.

For Medicare adding new HCPCS codes to the list of telehealth services on a category 1, and the HCPCS codes are G0316, G0317, G0318, G3002, and G3003.

We are keeping many services that are temporarily available as telehealth services for the duration of  the COVID-19 Public Health Emergency (PHE) on a Category 3 basis through CY 2023 and including the following CPT codes.

The CPT codes are 90875, 90901, 92012, 92014, 92550, 92552, 92553, 92555-92557, 92563, 92567, 92568, 92570, 92587, 92588, 92601, 92625-92627, 94005, 95970, 95983, 95984, 96105, 96110, 96112, 96113, 96127, 96170, 96171, 97129, 97130, 97150-97158, 97530, 97537, 97542, 97763, 98960-98962, 99473, 0362T, and 0373T. 

These codes are available up to through December 31, 2023 in Medicare telehealth list.

The Category 3 CPT codes in telehealth services will be covered through 2023 and the Non-facility payment rates for telehealth services will remain the same through 2023 (physician offices are defined by Medicare as “Non-Facility” setting.

So this means telehealth payments will remain the same as in-person through 2023 and the direct supervision may continue to be provided virtually through 2023.

The CMS decided to continue paying for all of the codes on the telehealth list that were scheduled to stop 151 days after the PHE through the end of 2023.

Telehealth Originating site facility fee rate Update

The payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80% of the lesser of the actual charge, or $28.64 for CY 2023 services.

Other than office visit codes, the E/M visits includes following,

• Hospital inpatient, 
• Hospital observation, 
• Emergency department, 
• Nursing facility, 
• Home services, 
• Residence services, and 
• Cognitive impairment assessment visits.

For 2023, Medicare adopting the revised CPT codes for Other E/M visits (except for prolonged services)

• G0316 for reporting prolonged hospital inpatient or observation services
• G0317 for prolonged nursing facility services
• G0318 for prolonged home or residence services
• G2212, for  prolonged office/outpatient services
• G3002 - Chronic Pain Management
  
• G3003 - Chronic Pain Management 

Place of Service Updates

The place of services code is provided to pay the claims correctly at the same time the health care providers need for the specificity than Medicare for the services rendered. And the Medicare does not always need this greater the specificity to pay the claims.

The following two codes are created to meet the industry standards,

POS 02: Telehealth Provided Other than in Patient’s Home Descriptor

• The location where health services and health related services are provided or received, through telecommunication technology. 
• Patient is not located in their home when receiving health services or health related services through telecommunication technology. 

POS 10: Telehealth Provided in Patient’s Home Descriptor

• The location where health services and health related services are provided or received through telecommunication technology. 
  
• Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology

But the Medicare does not identified a need for new place of service code (POS 10). The MACs will instruct their providers to continue to use the Medicare billing instructions for Telehealth claims in specified under section Pub. 100-04.

Evaluation and management 2023 updates

Evaluation and Management 2021 Updates 

The E&M 2021 changes primarily focused on the documentation and coding guidelines for office and outpatient visits (commonly referred to as E&M codes 99202-99215). 

The main goals of these changes were to reduce administrative burden, simplify documentation, and recognize the value of cognitive work performed by healthcare professionals.

Key aspects of the E&M 2021 changes included

The Elimination of history and physical examination requirements as key components for code selection.

The E&M guidelines now allow providers to choose the level of service based on either Medical Decision Making (MDM) or Total time spent on the encounter. 

While the documentation of the history and physical examination is still important for patient care, it is not required to determine the appropriate code level but it should be documented in the medical records.

A Revised guidelines for code selection based on medical decision-making (MDM. The MDM now has a greater role in a code selection. 

The E&M guidelines provide clear definitions and examples of the components of MDM, such as.,

1. Number and complexity of problems addressed,
2. Data reviewed and analyzed, and
3. Risk of complications or morbidity.

Guidelines for Time Based Code Selection

Expansion of time as a determining factor for code selection. The Providers can now select the code level based on total time spent on the patient encounter, including both face-to-face and non-face-to-face time.

This change benefits providers who spend a significant amount of time on activities like care coordination, reviewing records, and discussing cases with other healthcare professionals.

E&M Updates for 2023 

Initially the above said guidelines were introduced to use only for office and outpatient visits and now , effective from Jan 1st 2023, these guidelines will be applicable for across all the level of E&M code selection. 

 There are some new guidelines Introduced for the specific services,

• Hospital Inpatient and Observation (99221 to 99223, 99231 to 99239)
• Emergency Department Visits (99281 to 99285)
• Consultations codes (99242-99245, 99252-99255)
• Nursing Facility Services codes (99304-99310, 99315, 99316)
• Home or Residence Services codes 99341, 99342, 99344, 99345, 99347-99350

Glimpses of 2023 Changes and Updates

• Deletion of Hospital Observation Services E/M codes 99217-99220
• Revision of Hospital Inpatient and Observation Care Services E/M codes 99221-99223, 99231-99239 and guidelines
• Deletion of Consultations E/M codes 99241 and 99251
• Revision of Consultations E/M codes 99242-99245, 99252-99255 and guidelines
• Revision of Emergency Department Services E/M codes 99281-99285 and guidelines
• Deletion of Nursing Facility Services E/M code 99318
• Revision of Nursing Facility Services E/M codes 99304-99310, 99315, 99316 and guidelines
• Deletion of Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services E/M codes 99324-99238, 99334-99337, 99339, 99340
• Deletion of Home or Residence Services E/M code 99343
• Revision of Home or Residence Services E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines
• Deletion of Prolonged Services E/M codes 99354-99357
• Revision of guidelines for Prolonged Services E/M codes 99358, 99359, 99415, 99416
• Revision of Prolonged Services E/M code 99417 and guidelines
• Establishment of Prolonged Services E/M code 993X0 and guidelines

Summary of Hospital inpatient and observation Changes

The Observation Care Discharge Services CPT 99217 has been deleted. 

• To report observation care discharge services, see 99238, 99239

Initial Observation Care New or Established Patient 99218, 99219, 99220 have been deleted. 

• To report initial observation care, new or established patient, see 99221, 99222, 99223 

Subsequent Observation Care 99224, 99225, 99226 have been deleted. 

• To report subsequent observation care, see 99231, 99232, 99233
  

Revised CPT Code Description

Admission Service (Initial hospital inpatient or observation)

99221 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making.

When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.

99222 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.

When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.

99223 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.

When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.

Follow up Service (Subsequent hospital inpatient or observation)

99231 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically
appropriate history and/or examination and straightforward or low level of medical decision making.

When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

99232 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.

When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.

99233 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.

When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.

Discharge Service - Hospital inpatient or observation

99238 Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter.

99239 more than 30 minutes on the date of the encounter.

For hospital inpatient or observation care including the admission and discharge of the patient on the same date, see 99234, 99235, 99236

*** For 99211 and 99281, the face-to-face services may be performed by clinical staff

Golden Rule - Pulse Oximetry with Evaluation & Management

CPT Code Description: -

94760 - Noninvasive ear or pulse oximetry for oxygen saturation; single determination

94761 - Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (e.g., during exercise) 

The provider and or other qualified healthcare professional takes the oxygen saturation using the a sensor on the ear or finger from the patients.

To perform this service, the doctor places a sensor, such as one in the form of a clip, on the patient’s earlobe or fingertip.

The sensor uses a light shining through the body part to measure the oxygen saturation, detecting the differences in the ways blood cells with and without oxygen reflect light.
 

The Oxygen saturation, is also called as O2 sat, and the percentage of hemoglobin carrying oxygen molecules.

 

Guidelines: -

The CPT Codes ranges from 94010 to 94799 include laboratory procedure(s) and interpretation of test results.

If a separate identifiable evaluation and management service is performed on the same day, the appropriate E/M service code can be billed separately. Like,

• New or Established Patient Office or Other Outpatient Services (99202 to 99215),
• Office or Other Outpatient Consultations (99242 to 99245),
• Emergency Department Services (99281 to 99285),
• Nursing Facility Services (99304 to 99316),
• Home or Residence Services (99341 to 99350),

The mentioned above listed CPT codes may be reported with modifier 25 based on the NCCI edits guidelines in addition to the 94010-94799.

General Information: -

The pulse oximetry codes are not reportable with any other service performed on the same day.

There is no NCCI edits for this CPT codes, but as per the CMS guidelines, the Medicare Physician as categorized into the "T" status code, which means they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.

Additional Information: -

Pulmonary function tests (94011-94013) are reported for measurements in infants and young children through 2 years of age.

Pulmonary function testing measurements are reported as actual values and as a percent of predicted values by age, gender, height, and race.

Evaluation and Management (E/M) Services - Domiciliary or Rest Home Environment

Domiciliary, Rest Home, or Custodial Care Services CPT codes 99324 - 99337

Domiciliary, Rest Home (e.g. Boarding Home), or Custodial Care Services, are used to report E/M services to individuals residing in a facility which provides room, board, and other personal assistance services, generally on a long-term basis. 

These codes are also used to report E/M services in an assisted living facility. The facility’s services do not include a medical component.

A home or domiciliary visit includes a patient History, Physical Examination and Medical Decision Making in various levels depending upon a patient’s needs and diagnosis. 

The visits may also be performed as counseling and/or coordination of car, when medically necessary outside the office environment and are an integral part of a continuous of the patient's care. 

The patients seen may have chronic conditions, may be disabled, either physically or mentally, making access to a traditional office visit very difficult, or may have limited support systems. 

The home or domiciliary visit in turn can lead to improved medical care by identification of unmet needs, coordination of treatment with appropriate referrals and potential reduction of acute exacerbation of medical conditions, resulting in less frequent trips to the Hospital or Emergency services.

The home-based health care is rapidly expanding and growth in hospital-based house call programs. 

The Physicians and qualified non-physician practitioners (NPPs) are required to oversee or directly provide progressively more involving a great deal of worldly experience and knowledge of fashion and culture for home visits. 

A Patients must understand the nature of a pre-arranged visit and consent to treatment in the home or domiciliary care facility. There is no requirement that the patient must be homebound. 

If the service is provided to a patient for the first time, the patient, his/her delegate, or another medical provider managing the patient’s care, must request the service. The visiting provider may not directly solicit referrals. 

• An example of inappropriate solicitation is knocking on residents’ doors or placing calls to residents on the telephone to offer medical care services when there has been no referral from another professional that is already involved in the case.

If laboratory and diagnostic tests are performed during the course of home or domiciliary care visits, they must be documented in the medically necessary reason. Medical reasons for repeat testing must be clearly documented.

Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). 

The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

Many elderly patients have chronic conditions, such as hypertension, diabetes, orthopedic conditions, and abnormalities of the toenails. 

Required Criteria

• A home or domiciliary care visit must meet all of the following criteria.

• Chief complaint or a specific, reasonable, and medical necessity is required for each visit.

• A payable diagnosis alone does not support medical necessity of ANY service.

• Medical necessity must exist for each individual visit.

• Visit will be regarded as a social visit unless medical record clearly documents medical necessity for every visit.

• Service/visit must be medically reasonable and necessary and not for physician or qualified NPP convenience.

• Service must be of equal quality to a similar service provided in an office.

• Frequency of visits required to address any given clinical problem should be dictated by medical necessity rather than site of service.

• It is expected that frequency of visits for any given medical problem addressed in home setting will not exceed that of an office setting, except on rare occasion.

• Training of domiciliary staff is not considered medically necessary.

• The E/M service will not be considered medically necessary when it is performed only to provide supervision for a visiting nurse/home health agency visit(s).

Acceptable Location 

Home based services are provided services which are performed in,

• Private Residence - Home, apartment, town-home etc.

• Domiciliary Care Facility - A home providing mainly custodial and personal care for persons who do not require medical or nursing supervision, but may require assistance with activities of daily living because of a physical or mental disability. This may also be referred to as a sheltered living environment.

• Rest Home - A place where people live and are cared for when they cannot take care of themselves.

• Custodial Care Services - Custodial care is non-medical assistance, either at home or in a nursing or assisted-living facility with the activities of daily life (such as bathing, eating, dressing, using the toilet) for someone who's unable to fully perform those activities without help.

• Residential Substance Abuse Facility - A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents.

Place of Service (POS) Codes

• 12 - Home
• 13 - Assisted Living Facility (adult living facility)
• 14 - Group Home
• 33 - Custodial Care Facility
• 55 - Residential Substance Abuse Facility

Domiciliary, Rest Home, or Custodial Care Services Listing -CPT 99324 to 99337

CPT   Code Description

99324 Level 1 new patient domiciliary, rest home, or custodial care visit  

99325 Level 2 new patient domiciliary, rest home, or custodial care visit

99326 Level 3 new patient domiciliary, rest home, or custodial care visit

99327 Level 4 new patient domiciliary, rest home, or custodial care visit

99328 Level 5 new patient domiciliary, rest home, or custodial care visit

99334 Level 1 established patient domiciliary, rest home, or custodial care visit

99335 Level 2 established patient domiciliary, rest home, or custodial care visit

99336 Level 3 established patient domiciliary, rest home, or custodial care visit

99337 Level 4 established patient domiciliary, rest home, or custodial care visit

Home Visits Listing - CPT codes 99341 - 99350

• The Home Services codes, are used to report E/M services furnished to a patient residing in his or her own private residence. 

• The Private residence considered following, Private home, an apartment, or town home.

CPT    Code Description

99341 Level 1 new patient home visit

99342 Level 2 new patient home visit

99343 Level 3 new patient home visit

99344 Level 4 new patient home visit

99345 Level 5 new patient home visit

99347 Level 1 established patient home visit

99348 Level 2 established patient home visit

99349 Level 3 established patient home visit

99350 Level 4 established patient home visit

Refer New Patient vs. Established Guidelines

Smoking Cessation Counselling

Smoking Cessation

The following codes are used to report the preventive medicine evaluation and management of infants, children, adolescents, and adults.

Modifier 25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

• 99406 – Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 
• 99407 – Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes 

Required Documentation

• Patient Current smoking details 
• Time 
• Counseling Content 

Covered ICD Codes 

• F17.210 - Nicotine dependence, cigarettes, uncomplicated

• F17.211 - Nicotine dependence, cigarettes, in remission

• F17.213 - Nicotine dependence, cigarettes, with withdrawal

• F17.218 - Nicotine dependence, cigarettes, with other nicotine-induced disorders

• F17.219 - Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders

• F17.220 - Nicotine dependence, chewing tobacco, uncomplicated

• F17.221 - Nicotine dependence, chewing tobacco, in remission

• F17.223 - Nicotine dependence, chewing tobacco, with withdrawal

• F17.228 - Nicotine dependence, chewing tobacco, with other nicotine-induced disorders

• F17.229 - Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders

• F17.290 - Nicotine dependence, other tobacco product, uncomplicated

• F17.291 - Nicotine dependence, other tobacco product, in remission

• F17.293 - Nicotine dependence, other tobacco product, with withdrawal

• F17.298 - Nicotine dependence, other tobacco product, with other nicotine-induced disorders

• F17.299 - Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders

Clinical Example

The patient confirms the use of tobacco products (specify the product). Smoking 4 cigarettes per day.  

Spent 10 minutes for counseling and patient education about the dangers of smoking, health risk, and education hand out given to the patients for awareness. 

Discussed in detail complications with treatment plan due to continued use of tobacco products. The patient listen carefully and accepted to stop smoking  

Skilled Nursing Facility 3-Day Rule Billing

To qualify for Skilled Nursing Facility (SNF) extended care services coverage, Medicare patients must meet the 3-day rule before SNF admission. 

The 3-day rule requires,

• Three-day-consecutive inpatient hospital stay. 
• Three-day-consecutive stay counts inpatient setting.
• Starting with the calendar day of hospital admission.
• Doesn’t include the day of discharge or any pre-admission time spent in the ER or outpatient observation.

SNF extended care services are an extension of care a patient needs after a hospital discharge or within 30 days of their hospital stay (unless admitting them within 30 days is medically inappropriate).

Example

A 68-year-old male patient went to the hospital ER after falling on May 17th from his home and a physician admitted him to the hospital on the same day. On subsequently May 20, the hospital discharged him to SNF extended care services. 

For this case, the patient did qualify the 3-day rule. Hospitals can count the admission day (May 17th to May19th), but not the discharge day (May 20). 

Tips

Medicare considered inpatients meet the 3-day rule by staying 3 consecutive days in 1 or more hospital(s) as well.

See Inpatient Guidelines

RPM - Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) technology comes in various devices that monitor glucose levels, BP, weight management, sleep patterns, heart rate, vital signs, and many other types of patient data.

RPM allows patients to be involved in their own care by giving them access to their health data in real-time.

For providing RPM services to the patients and staff time spent monitoring the respective beneficiary. These actions are billable through four CPT codes,

• 99453 - Initial set up and patient education
• 99454 - Supply of devices and collection, transmission, and summary of services
• 99457 - First 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP
• 99458 - For an additional 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP

Initial Set-Up & Patient Education - CPT 99453

• It is reported for each episode of care.

• An episode of care is defined as beginning when the remote monitoring physiologic service is initiated and ends with the attainment of targeted treatment goals.

• CPT 99453 should not be reported, “If monitoring is less than 16 days.” If, for example, a patient receives and is educated on the device, but no data is transmitted by the device, one could not bill for CPT 99453.

Supply of Device - CPT 99454

• It is used to report the supply of the device for daily recording or programmed alert transmissions over a 30-day period provided monitoring occurs at least 16 days during the 30-day period.

• CPT 99453 & 99454 should not be reported “when these services are included in other codes for the duration of time of the physiologic monitoring service" (e.g., 95250 for continuous glucose monitoring requires a minimum of 72 hours of monitoring).

Monitoring & treatment Management services - CPT 99457 & 99458

• It requires live, interactive communication with the patient/caregiver and 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month.

• Can be billed once in 30 days.

• Time spent by clinical staff may be counted toward the 20 minutes only if services are furnished under direct supervision.

CPT Guidelines

• Time of fewer than 20 minutes during a calendar month cannot be billed with CPT 99457.

• Time over 20 minutes in one month cannot be carried forward to the next month.

• 99457 may be reported during the same service period as chronic care management services (99487, 99489, 99490), transitional care management services (99495, 99496), and behavioral health integration services (99484, 99492, 99493, 99494). 

• However, time spent performing these services should remain separate and no time should be counted toward the required time for both services in a single month.

• Report CPT 99457 one time regardless of the number of physiologic monitoring modalities performed in a given calendar month.

• “live interactive communication,” means a face-to-face visit, an interactive video conference (e.g., Face Time), or a conversation by telephone or text message would be sufficient. A record of such communication should be included within the documentation for the service.

RPM Billing Requirements

• The place of service would be the location at which the billing physician maintains his or her practice (i.e., physician office vs. hospital outpatient department).

• A beneficiary may have two monitoring devices with one supplied by the physician monitoring one chronic condition and one by another physician monitoring another condition, and both physicians would be eligible for payment.

See Complex Chronic Care Service

Evaluation and Management - Inpatient Setting

Initial hospital care is reported for a patient who is being admitted to the hospital as an inpatient. The level of service is decided based on the three major key components of history, examination, and medical decision-making.

There are divided into three types.

1. Inpatient Admit or Initial Care - 99221,99222 & 99223
2. Subsequent Hospital or Follow Up - 99231, 99232 & 99233
3. Discharges - 99238 & 99239

Guidelines

Do not report another E/M service along with the inpatient admission code even though if the patient is seen by the same physician for a different reason on the same day.

E.g., 

The physician sees the patient in the ED and after a thorough examination, decides to admit the patient to the hospital.

Report only the appropriate level of inpatient admission code and the ED service is considered the part of admission services when the same service is rendered by the same provider.

If the admission is on a subsequent date from an ED service, both the services can be reported respectively. 

Same day Admission and discharge refer below CPT codes,

• 99234 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A detailed or comprehensive history, A detailed or comprehensive examination; and straightforward or of low complexity of MDM
• 99235 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and moderate complexity of MDM
• 99236 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and High complexity MDM

Additional Information

The selection of a level of E/M service depends mainly on the three major components: 

• History, Examination, and Medical Decision Making (MDM). 
• The other components that might affect the decision-making are the nature of presenting the problem, time, coordination of care, and counseling.

History consists of four components: Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), and Past Family and Social History (PFSH).

Physical Examination: Physical examination is the examination of the organ systems or different body areas relevant to the current disease/disorder.

MDM -Medical Decision Making: After gathering information, the clinician must decide what to do. That thinking process, which takes into account risk factors, is MDM.

It has three components like,

• A number of diagnosis and treatment options.
• The amount and/or complexity of data reviewed.
• The risk of complications, morbidity, and/or mortality involved.

Tips

The admitting physicians can be reported with modifier "AI" for CPT 99221 to 99223 when the patient has "Medicare and Medicare HMO's" insurances since Medicare & HMO's plan would not be covered Consultation services hence Consulting physician can be reported the admit CPT's.

When more than one admits service is billed within the same inpatient setting, the modifier "AI" is denoted as " Principal physician" it will help the insurance to identify the admitting physician's name vs Consulting Physician's names.


Return to related information

Level of History - Evaluation and Management

Definition and Details of  History

Level of  History

There are four levels of History found in E/M,

• Problem Focused History
• Expanded Problem Focused History
• Detailed History
• Comprehensive History  

The problem focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), 

The Expanded Problem Focused History requires documentation of the chief complaint (CC) and a brief history of present illness (HPI) and Problem Pertinent review of system

The Detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS), and pertinent past, family, and/or social history (PFSH).

The Comprehensive history requires the documentation of a CC, an extended HPI, plus an Complete review of systems (ROS), and Complete past, family, and/or social history (PFSH).

Chief Complaint (CC) 

A Chief Complaint or reason visit/ reason for appointment is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. 

The CC is usually stated in the patient’s own words. For example, patient complains of chest pain and radiating to shoulder, and  denied shortness of breath. The medical record should clearly reflect the CC.

History of Present Illness (HPI) 

The HPI is a chronological description of the development of the patient’s present illness from the first sign and/ or symptom or from the previous encounter to the present

The HPI elements are,

• Location (example: left leg)
• Quality (example: aching, burning, radiating pain)
• Severity (example: 10 on a scale of 1 to 10)
• Duration (example: started 3 days ago)
• Timing (example: constant or comes and goes)
• Context (example: lifted large object at work)
• Modifying factors (example: better when heat is applied)
• Associated signs and symptoms (example: numbness in toes) 

There are two types of HPI,

A Brief HPI includes documentation of one to three HPI elements. 

An Extended HPI, 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities. In 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions

Review of Systems (ROS)

ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced. 

These systems are recognized for ROS purposes,

• Constitutional Symptoms (for example, fever, weight loss)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

The three types of ROS are problem pertinent, extended, and complete.

A Problem Pertinent ROS inquires about the system directly related to the problem identified in the HPI

An Extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.

A Complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. 

• The Provider must individually document those systems with positive or pertinent negative responses. 

• For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems.

Past, Family, and/or Social History (PFSH)

PFSH consists of a review of three areas,

1. Past history includes experiences with illnesses, operations, injuries, and treatments

2. Family history includes a review of medical events, diseases, and hereditary conditions that may place the patient at risk

3. Social history includes an age-appropriate review of past and current activities

The two types of PFSH are pertinent and complete

A Pertinent PFSH is a review of the history areas directly related to the problem(s) identified in the HPI. 

The pertinent PFSH must document at least one item from any of the three history areas.

A Complete PFSH is a review of two or all three of the areas, depending on the category of E/M service. 

A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient. 

For Details of MDM 

Critical Care Guidelines - CPT 99291 and 99292

Critical care is the direct delivery by a physician(s) or other qualified health care professional of 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 services include the treatment of vital organ failure or prevention of further life-threatening conditions. 

Delivering medical care in a moment of crisis and in time of emergency is not the only requirement for providing Critical Care services.

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. 

Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the level of attention mentioned above.

Key Points

The Critical Care Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes.

Critical care and other E/M services may be reported to the same patient on the same date by the same individual.

The critical care code is applicable for a critical care service provided for the first 30 – 74 minutes. Any Critical Care service provided for less than 30 minutes should be billed with the appropriate level of E/M code.

Usually, a Critical Care service is provided to a patient in a "Critical Care Area" such as,

• Coronary Care Unit (CCU), 
• Intensive Care Unit (ICU), 
• Respiratory Care Unit, or 
• Emergency Room.

Included Services

The mentioned below list of services are included when performed during the "Critical Care service"

• Interpretation of cardiac output measurements - 93561, 93562
• Chest X rays -71045, 71046
• Pulse oximetry - 94760, 94761, 94762[blood gases, and collection and interpretation of physiologic data] (eg, ECGs, blood pressures, hematologic data);
• Gastric intubation - 43752, 43753
• Temporary transcutaneous pacing - 92953 
• Ventilatory management - 94002-94004, 94660, 94662 
• Vascular access procedures - 36000, 36410, 36415, 36591, 36600

Any services performed that are not included in this listing should be reported separately. Facilities may report the above services separately.

Tips

Inpatient critical care services provided to neonates (28 days of age or younger) are reported with the neonatal critical care codes 99468 and 99469. 

Inpatient critical care services provided to infants 29 days through 71 months of age are reported with pediatric critical care codes 99471-99476

To report critical care services provided in the outpatient setting (eg, emergency department or office), for neonates and pediatric patients up through 71 months of age, see the critical care codes 99291, 99292

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Online Digital Evaluation e-visits

Guidelines

• Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs). 

• It requires a physician or other QHP's evaluation, assessment, and management of the patient. 

• These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. 

• While the patient's problem may be new to the physician or other QHP, the patient is an established patient. 

• Patients initiate these services through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the physician or other QHP.

• Online digital E/M services are reported once for the physician's or other QHP's cumulative time devoted to the service during a seven-day period. 

• Physician's or other QHP's cumulative service time includes a review, Initial inquiry,  review of patient records or data pertinent to an assessment of the patient's problem, 

• The personal physician or other QHP interaction with clinical staff focused, the patient's problem, development of management plans, 

• Including physician- or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service. 

• When the online digital inquiry is related to a surgical procedure and occurs during the postoperative period of a previously completed procedure, then the online digital E/M service is not reported separately. 

• When the patient generates the initial online digital inquiry for a new problem within seven days of a previous E/M visit that addressed a different problem, then the online digital E/M service may be reported separately. 

• When the patient presents a new, unrelated problem during the seven-day period of an online digital E/M service, then the physician's or other QHP's time spent on evaluation, assessment, and management of the additional problem is added to the cumulative service time of the online digital E/M service for that seven-day period.

Physicians

• CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 99422 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 99423 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 or more minutes

Non-physicians (NP & PA)

• CPT 98970 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 98971 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 98972 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 OR more minutes

2021 E&M Changes