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General E/M Information

  1. Where is the NGS E/M training tool/scoresheet located on the NGS website?

    Answer:
    Evaluation & Management Documentation Training Tool is located under the Medical Policy & Review tab, then Policy Education Topics > Evaluation and Management > Evaluation & Management Documentation Training Tool. Updated 6/9/2017
     
  2. As per the CMS 2019 Final Rule, providers may now reference information obtained and documented at a previous encounter, as long as the provider clearly documents current performance of all pertinent E/M elements and updates and/or modifies the record of the previous encounter. Please specify any further recommendation(s) relative to this change.

    Answer:
    The electronic medical record is generally capable of storing an extensive volume of prior documentation. CMS and NGS are concerned with “copy and paste” capability for these records, allowing providers to copy previous information without careful review. Providers are strongly encouraged to avoid any “copy and paste” function when documenting a service. When referencing earlier information, the provider should include the date of the prior service, a review of that information relative to the current service and also enter any update or modification to the prior information. Revised 4/17/2019
     
  3. Can a provider request a review of notes to see if NGS agrees that the clinical documentation meets the code description? Is there a method for this and if so what are the steps?

    Answer:
    NGS does not perform voluntary review of medical records for this purpose. We suggest that you attend our scheduled educational sessions on these topics, where your issues can be addressed. Other specific questions will be referred to NGS POE via the NGS PCC. Updated 6/9/2017
     
  4. During a SNF stay, patients are occasionally seen at a provider’s office. What is the correct coding for these services?

    Answer:
    For patients seen during a covered SNF stay, claims should be submitted with POS 31. For patients seen during a noncovered SNF stay, claims should be submitted with POS 32. The office-based physician should choose the correct E/M CPT code from the SNF family of E/M services. CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 80.4 (422. KB) states, 

“For example, if SNF inpatients are taken to the private office of a neurologist for necessary tests such as an encephalograph, the services are considered performed in the SNF for billing and payment.” Updated 6/9/2017

  1. When is it appropriate to bill CPT code 99211? Can this be used for medication renewals? Does it require the physician or an APRN to be present? Does the patient needs to be present (i.e., that service cannot be provided via phone)? Are there time duration limitations?

    Answer:
    CPT code 99211 represents a patient service that does not require the physician’s direct interaction, but must meet the incident to requirements for physician’s presence in the office suite. For example, this code may be appropriate for medication renewals if there is documented interaction by clinical staff with the patient regarding the medication, but does not represent the patient coming into the office to pick up a new prescription at the reception desk. The patient has to be present in the office and telephone services are excluded. There is no duration limit on time for the visit, although the suggested time is five minutes. Updated 6/9/2017

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