Ask-the-Contractor Teleconference Summary for 3/30/2023

Event Summary

Gail Toussaint welcomed 153 participants to the call. Attendees were informed that this call is intended for providers in Jurisdiction 6 and K, which consists of the states of Illinois, Minnesota, Wisconsin, Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont. The purpose of the call was discussed and the question and answer portion of the call was explained. Participants were informed of the different members of the National Government Services staff who were on the call to assist with questions.

Before the question box was opened, Nathan discussed a few topics. He discussed the end of the PHE, scheduled for 5/11/2023 and reviewed different resources to access when you need information on the PHE, changes, etc. CMS provided a roadmap for the end of the PHE. There are fact sheets based on differing specialties that may be beneficial, which include information on the waivers and policy changes, as well as when some flexibilities will end as there are varying dates. Nathan also reviewed upcoming changes to telehealth, E/M services, and more.

Effective 5/12/2023, condition code DR and modifier CR will no longer be allowed at the end of the PHE. Modifier CS to bypass coinsurance for cost sharing will no longer be in place. G9603 and G9604, travel allowance codes will return to editing to tie that allowance to specimen collection. If you are billing for a travel allowance, there should be a specimen collection as well, that the travel allowance is being billed for. Those two go hand in hand and are part of the same service. The ambulance waiver for the extension of timely filing will no longer be in place. Laboratory billing requirements for ordering/referring physicians that are in place for other radiology and diagnostic testing services will be required for COVID-19-related testing as well. For the PHE, CMS did not make that mandatory. Beginning May 12, if the patient has a lab test for COVID-19-related symptoms, you need to have a referring or ordering physician on that claim. Ambulance destination modifiers, local editing will be back in place as well. Ambulance policy will come back into place as it was prior to the PHE being issued.

The question box was opened and Nathan invited attendees to ask their questions.

How is NGS counting data in column 2, when a provider documents the review of prior external records from an outside source and provides an analysis from those records of multiple tests (i.e. CBC, A1C and chest X-ray)? Is this counted as all one source no matter how many progress notes and tests are reviewed and analyzed, as the AMA notes that review of materials from one unique source counts as one element toward the MDM? Or can we count the four individual tests that are being analyzed and documented as reviews of tests to equate to a moderate data in column 2?

Answer: We follow the AMA definition for external sources. The external records are indicated by physician or group. If they meet the external records definition as established by the AMA they would qualify.
Does the statement, “>30 minutes spent on discharge” meet the requirements of time when billing CPT code 99239? I thought that I read that CERT was down coding when the statement was used?

Answer: If you are billing greater than 30 minutes, we need to know the total number of minutes that were provided. Just making a statement saying “greater than 30 minutes” does not prove to an auditor the amount of time that was spent – there needs to be some indication in the medical record of how much time was spent. If it is greater than 30, then you can bill the code for that.
Can physical therapists, occupational therapists and speech language therapists establish a diagnosis that is different from the diagnosis that the PCP established after the therapist evaluates the patient and a better diagnosis is supported? Should this new diagnosis be signed off on the plan of care when PCP certifies it before it goes on the claim?

Answer: The diagnosis needs to be specific and relevant to the problem. In most cases, the medical diagnosis from the physician and an impairment diagnosis. The diagnosis is a required element of the plan of care which the physician would have to be in agreement with and the physician/NPP certified that in the plan of care. The ICD-10 code that best relates for the reason for the treatment should be reported. It can be changed, but it has to be in agreement between the two entities that are providing that service. The therapist cannot just override the physician and say this is what it needs to be.
For critical care, can 99291/99292 be split between two groups? One are MDs the other are PAs who would presumably be the same specialty as the MD group. There are two tax IDs.

Answer: That will not be a split/shared situation because for split/shared they have to be from the same group. Different Tax IDs, but not the same group. If two different specialties are providing two different types of critical care, from different groups, then they will be indicating their own services.
The general BHI code of 99484 can be billed under the PCP for the service performed by a clinical staff or social worker incident-to. The Medicare guide says incident-to billing rules are applied to this service except the rule of direct supervision. Medicare allows general supervision for this service. One of the incident-to billing rules says the billing and rendering providers must be employed in the same practice. Then, if the social worker and the billing PCP are employed in two different practices using two different Tax IDs, can this service of 99484 performed by the social worker be billed under the PCP?

Answer: The PCP is allowed to enter into a private contract with a social worker that is not linked to that PCP. The social worker could be considered a part of the care team if that occurs, but they would have to have that private contract. Keep in mind, it would be the PCP that would bill Medicare for the service, and then they would pay the social worker based on whatever agreement they have within that scenario.
In reading the FAQs for teaching physicians, it states that the attestation must include time that the teaching physician was present. Does this mean time that the teaching physician, resident, and beneficiary were all present? A lot of the time spent is coordination of care whose time does that include?

Answer: The main question, you have to include the time the teaching physician was present, there has to be an indication in the medical record of what each person is doing and the time they are involved in performing that service. This is especially so if you are billing based on time – it is a must. The documentation really needs to indicate who is doing what part of the service. If the physician and the resident are indicating they did this and they did that, it can be assumed the beneficiary was present for the service, there will be some indication the beneficiary was present.
Does Medicare cover prophylactic surgeries? For example, patient having mastectomy (only) due to being BRCA+ (Z15.01) – no other diagnosis for the surgery.

Answer: No, there has to be a medical necessity reason, which the overarching criteria in the Social Security Act is that medical necessity must be met. Medicare only covers services for medically necessary indications. Unless CMS were to add that to the Medicare coverage criteria, like they have for screening services.
Can providers who have the same tax ID but different taxonomy codes bill new patient visits? EX: Electrophysiology provider within a cardio practice or CT surgery within cardio practice.

Answer: Medicare Part B does not process according to taxonomy codes. They are not required. Medicare Part B processes according to physician specialty codes that CMS has established. If the two providers have different specialty codes, then yes, they can bill the new patient visits. If they are both cardiologists, and one has a subspecialty of electrophysiology, then the processing system is not going to allow that to go through because an electrophysiologist is a specialized type of cardiology. There might be a separate specialty code for electrophysiology – CMS has been working to make additional specialties available and add specialties to the Medicare covered listing. However, if they are the exact same specialty code, the answer is no. The sub-specialty can be provided in the NTE segment of the 2300/2400 loop that will let us know they are different and that may assist in your processing. Generally speaking, if the same specialty, they will not both be allowed.
From Medicare’s perspective, what differentiates a diagnostic facet injection from a therapeutic facet injection?

Answer: Diagnostic are to diagnose whether the patient has facet syndrome, and therapeutic services are facet joint procedures performed for pain relief or to address the conditions that are identified with the diagnostic test. We offer a local coverage determination, Facet Joint Interventions for Pain Management (L35936) specifically on facet joint injections if you wish to research further.
A patient comes in for an office visit. The patient’s chronic condition is stable, and the provider wants to continue the medication as it is currently prescribed for that condition. Is the provider required to document the medication dosage and frequency to continue in the assessment and plan to get credit for prescription drug management i.e., must they specifically state “continue medication A 40 mgs daily”? Or can they just say “stable/continue current medication” (without specifying the frequency and dosage)?

Answer: Overall, prescription drug management means they are looking at what the patient’s condition is and has been, documenting if the medication is working, how it is working, or how it is not working, you are describing the entire management service the physician rendered. You would document the medication they are on, the review of the dosage, how it is impacting the patients’ health and how it is performing.
When should we begin using Modifier 93 audio-only for NON-mental telehealth services?

Answer: CMS has not given any indication that they are going to require that modifier at this point.
Will residents working under the primary care exception still be able to code all levels of E/M after 5/11/2023?

Answer: No, they will not. Beginning 5/12/2023, the PHE is over and teaching physician services for residents for primary care exception will go back to the three levels of visits they are allowed to bill.
Teaching supervision can no longer be done via video after the PHE, does this mean that a resident and teaching physician must be physically together when doing telehealth visits now?

Answer: If they are in a rural area or a non-MSA, the telehealth policy will go back to pre-PHE rules. They will need to be together providing the telehealth service.
Can you confirm that NGS has loaded the JW and JZ modifiers for claims processing?

Answer: The JW modifier has been in the claims processing system for some time now. Providers can use both modifiers now, however, the JZ modifier is not required until July, 2023.
Regarding COVID-19 diagnostic testing, during the PHE CMS allowed to bill 99211 for specimen collection. Is this waiver expiring as of 5/11/2023?

Answer: Yes, CMS has indicated that you will go back to regular specimen collection, 99211 will go back to what 99211 has always been indicated for.
As of 2023, CPT 99358 for prolonged indirect service now has a status of "I" when in the years prior it was a status "A" code. I was wondering if there is a substitute CPT we could be billing in place of CPT 99358. Or have all indirect prolonged services been terminated?

Answer: CMS has indicated 99358 is no longer valid for Medicare reporting. For prolonged services, you would bill G0316 through G0318, or G2212 depending on the location of the patient where that service is being rendered.
Are there any CMS payable codes to capture lengthy medically necessary telephone calls, for example 90 minutes in length?

Answer: No, the telephone codes that are established are typically indicated for brief interactions with the patient and physician. CMS does not expect the call to be a lengthy level four or five E/M type service. There is nothing for that extended length of service.
Can a provider continue to render telehealth services from his home location (not in the office where he is enrolled in the Medicare program)? Does the provider need to be in the same state where the patient resides?

Answer: A provider can work from their home, that is a practice location, CMS has indicated through 2023, they can do that without reporting their home as a practice location in the group practice enrollment file, but once 2024 comes, the practice will need to have that physician’s home registered as a practice office location. Part 2: They do need to be in the same state that the patient resides. State licensing requirements will come back in place and you will have to be licensed in the state that you’re providing services to that patient in that state. The waiver was in place during the PHE but that will no longer be, at this time.
Does CMS require the teaching physician to personally document his/her presence for minor procedures, endoscopic procedures, and complex/high-risk procedures? The CMS Manual is specific for E/M, single surgery and two overlapping surgery. But not for minor procedures, endoscopy procedures or other complex or high-risk procedures.

Answer: In any teaching situation, the teaching physician is to document what they have done. That would be no different than any other procedure that is being performed, every physician/NPP resident are all expected to document what they have done.
Can 99214 be supported with an AWV with the assessment of stable chronic conditions with renewal of prescriptions or would the assessment of stable chronic conditions be included in the wellness service?

Answer: The AWV can be billed with an E/M visit, with the 25 modifier. The elements should not be the same as when you’re coding for the E/M. Whatever was included in the AWV should not be included in the E/M component. Also, when billing a separate E/M, it must be clinically justified.
Can the level of an incident-to encounter be billed based on the APP's total time only?

Answer: The nurse practitioner or physician assistant, if they are billing a service based on time, then it can be based on their time only.
When billing unlisted drug codes J3490, J3590 & J9999 unit of service has to be equal to 1. How do we report wasted units?

Answer: You will report two lines, one line will be the unlisted code with the JZ modifier, when that officially comes into place (in July) and the second line will be the unlisted code with the JW modifier. JW indicates wasted drug.
After the PHE ends, will Medicare continue to require the FQ modifier to be billed for audio-only mental health services?

Answer: Yes, that was part of the mental health service policy update.
When a provider orders a diagnostic test at one visit and reviews the results of the test at the follow up visit, does the physician get data credit for the review of those results?

Answer: No, if they ordered the diagnostic test and they bill for that diagnostic test, then they will not get credit for that. If someone else has billed for that test, if it is a test they ordered and they send out for someone else and they will review those results at the next visit, there will need to be documentation of what kind of review they did and why they felt the need to do the review. When the test is performed, whomever has done that, is paid for the technical and professional component that provides a report, the test results. Unless there is some medically necessary reason for re-review of the test result, it could not be counted.
Is the modifier 95 for telehealth services still needed for 99201– 99215 12/31/2023 or 12/2024?

Answer: Modifier 95 stays in place, and that was extended through 2024, according to the Consolidated Appropriations Act.
For split/shared E/M visits, does the MD have to personally document their portion or can the MD use the NPP documentation?

Answer: Physicians should be documenting their work. If the NPP is working as a scribe for the physician, then that would be ok. That would need to be indicated in the medical record. Generally speaking, every practitioner should be documenting their own work and what they have done.
Does Medicare allow a group visit or in other words SMA (Shared Medical Appointment)? It occurs when multiple patients are seen as a group for follow-up care or management of chronic conditions. Are there specific documentation and coding requirements?

Answer: CMS has not issued any specific policy for shared medical appointments. If you have multiple patients in for an appointment at the same time, it will still be viewed as a specific appointment and service for each patient. The medical records need to include documentation reflecting what was done for each patient in a shared medical visit situation. You also have the legal indications of the HIPAA to consider. You need to ensure the privacy and security piece is met as well.
If a patient presents for pain and the physician evaluates the pain and determines an injection is appropriate - is the E/M bundled into the injection procedure or can we bill for a separate E/M? Our understanding is that the procedure includes the evaluation if nothing else is performed or managed, then we would only bill the procedure.

Answer: No, that is part of the surgical procedure which is the injection. Every minor surgical procedure includes an E/M portion built into the allowance for that code. That is part of the RVUs set up for those minor surgical procedures. Any evaluation leading up to performing the injection is a part of that service and would not be separately billed.
Can steroids be used during diagnostic sacroiliac joint injection (SIJI)?

Answer: Please see the SIJI LCD and article that will provide you with this information.
When patient is under observation care and provider submits a code from any one of the following categories 99221-99223, 99231-99233, 99234-99236, 99238 and 99239 with outpatient POS, does the documentation have to state "patient under observation care" or is there a particular statement CMS is looking for?

Answer: Somewhere in the patients documentation we would expect an order or a request or something indicating they are being admitted into observation care. If there is an order for observation care indicated, there should be some kind of general note indicating the patient was seen under observation and so on.
For non-rural areas, does this mean telehealth is allowed until 12/31/2024 for ALL specialties?

Answer: The telehealth update from the physician and other clinician’s fact sheet discusses telehealth. Once the PHE ends, CMS has indicated all of those category three codes on the list will continue to be covered through 12/31/2023. They did indicate they are going to continue to look at changes to that too. The actual piece of the telehealth program itself, allowing it to be done outside of a rural area will continue through 12/2023 according to the Consolidated Appropriations Act.
If two different groups rendering critical care, one PA and one MD - same specialty, will concurrent care be an issue? Both would start with a 99291 on the same date of service.

Answer: If they are both working in the same specialty, critical care is still going to be looked at across those care lines. In the initial submission they may both be covered and paid but in an audit scenario, there is going to be a question raised by the auditing group as to why two different groups were brought in with the same specialty working in critical care and both billing. It would look like a type of unbundling situation where groups are trying to bill and both be paid for the same service.
Authorization is going to be required for injections - will the authorization be required for the facility and/or the provider?

Answer: We assume you are talking about the prior authorization for joint injections that are coming up. That is going to be the entire service, the facility has to provide or submit a prior authorization request. If the facility does not submit that in time, or does not get the prior authorization approved, then none of the services tied to that would be covered.
Does Medicare cover acne surgery or is it still considered cosmetic?

Answer: Just acne would be cosmetic. There has to be a medical indication for lesion removal.
When an APN is collaborating with or working within a specialty such as cardiology, are they considered the same specialty of the MD they are working with - meaning would they bill an established if they did a follow-up visit with the patient?

Answer: Yes, they are. A nurse practitioner or a physician assistant are general specialties in nature and they are considered to be a part of any other specialty that may be treating the patient. That is why you should use the NTE segment in the 2300/2400 loops to indicate they are working in a different specialty for that work.
Is 'geriatrics' considered a different specialty from adult med? Example: If a patient is established to adult med but new to geriatrics, can the geriatrics provider bill new patient visit code?

Answer: Adult Medicine is not an indicated CMS Medicare Specialty. Geriatrics is Specialty 38. So, if a Geriatric provider saw the patient in addition to another specific specialty then both may be covered.
AMA/CPT has defined discussion of management or test interpretation for category three as “an interactive exchange. The exchange must be direct and not through intermediaries (e.g., 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 (i.e., does not need to be in person), but it must be initiated and completed within a short time period (e.g. within a day or two).” Would a resident or fellow be considered a “trainee,” whereby the teaching physician would need to personally be present and documented as such, for the interactive exchange in order to count this category as part of the medical decision making?

Answer: A resident is not a trainee. A resident is a physician that is in training.
If a doctor is translating medical records from another country and reviews these records with the patient can this be counted as data points in category one?

Answer: No, that is not a data point that is just a service that needs to be provided so they can have an understanding of those records.
I understand certain telehealth services will end December 2023. Do we know what the list of 2024 telehealth services will be released so we can prepare our practice?

Answer: No, CMS has indicated they will review, and you should check out the physicians and other clinician’s fact sheet that I mentioned earlier, where it discusses the codes indicating they will no longer be allowed via telehealth at the end of 2023. If CMS makes changes for 2024, we expect to see those in the proposed rule that comes out in July.
What documentation requirements are required in an attestation by a teaching physician for an E/M service?

Answer: They just need to document what they did. What service they provided. They, as the physician, were present for the care of the patient. The key rule in any documentation, tell Medicare what you did, the thought process, what went into medical decision making. Think about an auditor that knows nothing about the patient, or the situation/service, the more complete the documentation, the better understanding they have of knowing what they did during the visit.
Does rural health stay the same for telehealth?

Answer: Yes, that is what the telehealth policy was set up for…rural health scenarios and situations.
For SIJ injections, confirming that no other injections can be performed at that same encounter?

Answer: You should check the correct coding initiative tables and the policy. Those two will tell you what cannot be billed separately and at the same time…if there are exceptions for that.
Can you confirm the time threshold for G0316? Is CMS now following the CPT time threshold?

Answer: CMS has established the prolonged services time can be billed once the total time has been met beyond what the relative value units (RVU) for each code or each service indicates is paid. The highest level code is paid, the RVU that allow payment for the service includes a higher number of minutes than included in CPT. We have this information on our website, you can also locate this on CMS’ website, and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30 that will be updated in May.
When does the allowance for the provider to be in a different state than the patient expire? Is that as of 5/12/2023 or end of 2023?

Answer: May 11 – the end of the PHE, the waiver is no longer in place.
Did I hear correctly that 99211 would no longer be billed for COVID-19 test collection as of 5/12/2023?

Answer: That is correct. That is not a specimen collection code. That is something CMS put in place for the COVID-19 clinics. It is a level 1 E/M service and the requirements of 99211 would need to be met.
Regarding “independent interpretation of tests” on AMA MDM table, if the MD orders a CT scan during initial clinic encounter, then at the next E/M clinic encounter, the MD independently interprets the CT image and documents his findings. Can the MD get credit for the independent interpretation of image performed at the second encounter, even though it was ordered by him at the initial encounter? The reason I ask is the AMA states in the E/M guidelines of CPT that “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.” I am not sure if this AMA CPT rule applies to only the “review” of test results or applies to both review and independent interpretation of actual image?

Answer: To address your question there are several pieces here. Did the ordering physician that you are talking about perform the interpretation originally? If not, they may be able to count it later. However, then the question is why did they need to do an independent interpretation? Doing another interpretation just to do it for them is not medically appropriate. Is there something that looks off on the original interpretation, or something in regard to new patient symptoms that warrant a new interpretation? If so, then it may be medically appropriate and counted. So, if the physician did not do the initial interpretation and there was some medical need for an independent interpretation, they could provide one and count that as long as the documentation justifies how it applies to medical decision making.
Regarding the correct date of service for a surgery that begins on one calendar date, say 11 p.m. and crosses midnight, finishing on the next calendar date; what is the correct date of service, the date the surgery began or ended? Is the correct date of service based on when anesthesia is induced or the date the initial incision is made?

Answer: The correct date of service is going to be the date the procedure began.
In a provider based hospital outpatient department, if a patient comes in for a suture removal performed by a nurse, is it appropriate to bill a 99211 on both a UB-04 claim and a CMS-1500 claim, or should that service only be reported once on the UB-04 claim?

Answer: No, a suture removal would not have both the professional service and the hospital portion billed on a UB-04 and the hospital, or anyone, cannot bill on a 1500 for a service provided by a nurse as they are not a Medicare provider. In this scenario the hospital may bill Part A for their portion of the space and professional services required to provide the service. However, there is no service here that would be billed to Medicare Part B.
Regarding substantive portion for split/shared visits based on time; per CPT rules, only distinct time can be counted. When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted. Is there a Medicare rule that dictates which provider gets to count this joint time? Meaning, if the MD independently spent 10 min with the patient and the NPP independently spent 15 min with the patient; then the MD and NPP jointly met with patient for an additional 10 min, for a total visit time of 35 min. Can the joint time of 10 min be given to the MD for a total of 20 min, making the MD the substantive provider, even though the MD’s individual time spent of 10 min was less than the NPP personal time?

Answer: No, Medicare has no policy about who can count the time when joint care is being provided. If both practitioners are working together the only requirement is that only one may count the time for that interaction. The only other piece would be documentation has to be clear for the time the physician is spending with the patient and showing it is the substantive portion.

The call was closed. We thanked the attendees for their participation and informed the group that the event summary would be posted to our website within 30 business days.

Posted 4/11/2023