Event Summary

Event/Question and Answer Summary

Event Summary

Gail O’Leary welcomed 224 participants to the call. Attendees were informed that this call is intended for providers in Jurisdiction 6 and Jurisdiction 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.

Nathan Kennedy discussed the following from the 2022 Physician Fee Schedule Final Rule. CMS issued CR12519 summarizing the policies regarding a multitude of policy changes. 

  • Medical Nutrition Therapy: No longer has to be the treating physician who can order the MNT services. 

  • Change related to physical therapy services were finalized and information regarding CQ and CO modifiers was communicated. 

  • The telehealth listing was updated. Anything listed in Category 3 was originally temporary during the PHE, but they have been extended through 2023 or the end of the PHE if later. Additional discussion will most likely occur, services were also added. View CMS' website for the List of Telehealth Services.

  • A change effective 1/1/2022 indicates there must be a nontelehealth service for patients receiving mental health telehealth services. The nontelehealth visit has to be within the previous six months prior to the telehealth services beginning, and every 12 months after. You have to make sure you are still having some regular contact with the patient in-person. 

  • Split/shared and critical care services: CMS did finalize new policies for split/share E/M services. A common question we have been receiving is asking about the time required to be documented in the medical record, this is nothing new, physicians should be documenting what they are doing in the patients’ medical record. When billing based on time, this is especially important, but also for medical decision making. All services should reflect a clear indication of what was done during the service. When it comes to substantive portion of visits, the doctor who provides the substantive portion is the physician the service should be billed under. The substantive portion can be history, the physical exam or MDM, or if billing based on time, more than half of the total time.  Reiterating for documentation, it should reflect who has done what portion of the visit. 

  • Regarding the modifier related to split/shared, CMS indicated the “FS” modifier should be appended to E/M services to indicate they are a split/shared service. CMS did clarify that split/share applies to a facility based setting and does not apply in an office practice setting. Split/shared can be reported for new, as well as established patients, and initial and subsequent visits as well as prolonged services. The final rule includes a table defining what the substantive portion would reflect as well as billing for prolonged service in a split/share visit. All of these policies will be contained in the Code of Federal Regulations, 42 CFR 415.140. 

The question box was opened and attendees were invited to ask their questions. The questions and answers below were addressed during the call, and via pre-submitted questions.

Question and Answer Summary

  1. How do I bill for mental health therapy done in the patient’s home and what code should I use for billing?

    Answer:  The code will be based on the service rendered. There is no set code assigned by Medicare. You have to match the code to the appropriate service rendered. As far as billing, assuming telehealth, nothing has changed with that. The new change indicating the service can be provided in an audio-only format is that you need to have the additional regular visit six months prior to the audio service and see the patient every 12 months thereafter. There has to be an in-person component based on those new guidelines with this type of service.

  2. Question about the new LCD for epidural steroid injections - Will lumbar spinal stenosis without radiculopathy be covered? 

    Answer: No, this is not listed as a payable diagnosis in the article.

  3. Is ICD-10-CM M48.061 (Spinal Stenosis without Neurogenic Claudication) still an acceptable code to use, the covered indications mentions neurogenic claudication and I have been told that if spinal stenosis is the diagnosis for the procedure, then the patient must have spinal stenosis with neurogenic claudication.

    Answer: M48.061 is listed as a payable diagnosis in the article.

  4. Have the imaging requirements (i.e. minimum of two views-fine needle position and contrast flow) and/or pain scale documentation changed?

    Answer: In the lumbar LCD the following is listed - films that adequately document final needle position and injectate flow must be retained and made available upon request. In the epidural steroid injection billing and coding article it states the following – films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request.

    The scales used to measure pain and/or disability must be documented in the medical record. Acceptable scales include, but are not limited to: Verbal rating scales, Numerical Rating Scale and Visual Analog Scale for pain assessment, and Pain Disability Assessment Scale, Oswestry Disability Index, Oswestry Low Back Pain Disability Questionnaire, Quebec Back Pain Disability Scale, Roland Morris Pain Scale, Back Pain Functional Scale and the Patient-Reported Outcomes Measurement Information System profile domains to assess function.

  5. Is the use of IV conscious sedation with epidural steroid injections a covered service?

    Answer: Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.

  6. For the IAF joint procedures, we just need clarification on the IA procedures, diagnostic and therapeutic. Patient can have diagnostic IAF if Medical Branch Blocks cannot be performed due to anatomic restrictions or there is an indication to proceed with therapeutic IAF (if the latter, patient can go right to therapeutic IAF)? What would be an indication that the patient should proceed with the therapeutic IAF rather than go through with two diagnostics? Once the patient has two diagnostic IAFs, if they are unable to proceed to the Radio Frequency Ablations they can continue with IAFs with the cap of four sessions per rolling 12 months?

    Answer: IAF injections are not covered unless there is justification in the medical documentation on why RFA cannot be performed. Facet joint procedures in patients for the indication of generalized pain conditions (such as fibromyalgia) or chronic centralized pain syndromes are considered not reasonable and necessary. Individual consideration may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. There are only unique or rare situations where a therapeutic IAF injection is done rather than having the two diagnostic injections. We cannot define any specific conditions.

    For therapeutic injections, documentation of why patient is not a candidate for RFA must be submitted for therapeutic treatment.

  7. Is modifier FQ limited to specific services?

    Answer: CMS has not published guidance to this point. We are not able to address policy or guidelines on that modifier yet.

  8. Will shared visits be appropriate in the office setting?

    Answer: Split/shared is not valid in POS 11 (office setting) for new or established patients. It does not apply to an office setting, only facility.

  9. Is NGS going to start using POS code 10 for telehealth services when the patient is located in their home and, if so, when?

    Answer: POS 10 was added and finalized as a new POS for patients receiving telehealth in their home. The MLN indicated they do not see a situation where they would require this to be billed, so it is not required. Providers may choose to do so and it will process correctly.

  10. Do the 2022 changes apply even if the PHE is in effect? Behavioral health audio only therapy and the face-to-face requirement? 

    Answer: Yes, they still apply regardless of the PHE. CMS indicated this would be effective 1/1/2022 and are not waived due to the PHE.

  11. Pertaining to consolidated billing, when do we bill to a Skilled Nursing Facility?  Do we still bill to the SNF with the modifier if we rent office space or practicing within the SNF?

    Answer: In a SNF consolidated billing situation, that is a situation where Medicare Part A pays the SNF facility for the entirety of the patients care. There are only a few exceptions, mainly with physician professional services that can be billed separately for the patient by the provider when they are in a SNF covered Part A stay. If a doctor goes into the SNF to perform an E/M service, they can bill for that service. If the patient is in a SNF-covered Part A stay and receives some sort of diagnostic testing, etc., everything involved in their total care, falls under the SNF payment for Part A. See CMS’ Consolidated Billing web page for assistance in determining what is covered under consolidated billing versus billing Medicare directly.

  12. HCPCS G0444 (depression screening up to 15 minutes) - how does the score of any tool affect the billing of this code? Does the patient’s score have to reach a certain level in order to bill for this service?

    Answer: No, the G0444 code description indicates you are using some type of tool to evaluate the level of depression the patient may or may not have. Results do not come into play in coding the service.

  13. Regarding the FT modifier, can you provide an example of appropriate versus inappropriate use of this modifier? Can you provide guidance on what you mean by unrelated to surgery?

    ​​​​​​​Answer: FT is the new modifier that CMS has indicated should be billed with critical care services when those services are provided within a global period of a surgery that the critical care is not related to the surgery that was performed. For instance, the patient comes in for a knee replacement and two months later they begin to have other health issues and they start to crash, critical care services are required to save their life, or to stabilize them. That is not related to the knee replacement procedure. The physician is going to determine that. If they have a heart attack and a week later their heart starts to give out, that would be related to the surgical procedure most likely. It depends on the case/situation and the physician should let you know whether it is related/unrelated to the surgical procedure.

  14. In regard to split/shared, how is performing a history only considered the substantial portion when another provider is clearly documenting exam and MDM?

    Answer: That would be a question for CMS. They did have some comments in relation to that from the proposed rule but we would not be able to answer that question. They have indicated in the interim year, they are allowing that to try to get everyone to the point they are ready for 2023 when the regular rules are in place.

  15. Can split/shared be billed in POS 22 for those office sites designated as clinics?

    ​​​​​​​Answer: If it is an office site, then no, depending on how you are enrolled in the Medicare Program, POS 22 is for an outpatient department, not an office site or a clinic.

  16. Can consults be a split/shared service?

    ​​​​​​​Answer: Consult codes are not billable to Medicare. Also, a consultation service by definition does not meet a split/shared situation.

  17. For mental health, the final rule expanded to every 12 months in-person visit after telehealth, however the transmittal number 12519 states for six months thereafter, should it have said 12?

    ​​​​​​​Answer: The final rule did indicate six months; however, CR12519 did then issue the final instruction to be at least every 12 months after.

  18. In regard to split/shared visits for critical care, if the MD provided the services for the first hour, and then the NP does the concurrent care, does the MD add the FS modifier to his/her first hour?

    ​​​​​​​Answer: For critical care, it is billed based on time, split/shared services can be performed for critical care, so if the MD is providing the service as split/share with the NP, then it will be billed under who does the substantive portion of the visit and that person is the one who will bill for the service. They will not be billed separately.

  19. In regard to telehealth for mental health services, the requirement that a face-to-face be met six months prior and every 12 months after. Can you explain the difference between mental health, and if the patient has a substance use disorder or co-occurring mental health diagnoses?

    ​​​​​​​Answer: An SUD is part of and considered mental health services. Those would apply.

  20. For split/shared, the billing provider is greater than 50%, so documentation would need to state at least 51% if billing based on time, correct?

    Answer: It does not need to have that specific statement, but the practitioner providing the service should be documenting what they are doing, and the medical record should show that who is billing the substantive portion is the one who did the substantive amount of work. That is all that needs to be clarified.

  21. How do you bill for mental health therapy done in person in a patient's home?

    ​​​​​​​Answer: If you are providing mental health services in a patient’s home, it will depend on the CPT code that is being billed, for instance, is that code appropriate to be billed outside of a medical setting, and in the patient’s home. In many cases it probably can be but it will depend on the code and what POS that code is allowed to be billed. If it is a mental health service requiring some medical portion that requires the service be done in an office, then that would not be appropriate. 

  22. If there are three key components, how can you tell what is substantive? Whoever does two components? Or what if a subsequent visit and two key components need to be met and an NP does one and the MD does another, how do you determine who to bill under?

    ​​​​​​​Answer: CMS has clarified whoever performs one of those three may be providing the substantive portion for CY 2022, it does not have to be two out of the three. 

  23. Will there be CMS Final Rule-related updates to the FAQs on NGS Medicare's website and if so, what is an estimated timeline?

    Answer: When any regulation is published, we review the FAQs to ensure they are updated appropriately. Since the final rule is effective in January, you can expect to see those updates also in January. 

  24. What E/M charge and psychotherapy codes are billable with audio only services for psychotherapy? NCCI edit and CPT are conflicting; one allows 99441-99443 and the add-on code for psychotherapy, and one does not. 

    Answer: You would need to look at the List of Telehealth Services CMS offers on their website. This list includes what can be billed via telehealth and what can be billed audio only. If there is a discrepancy between the CCI edits and what policy is, CCI edits may not always agree with CPT coding guidelines. You would need to dispute this with the CCI contractor, which can be located on the CMS website on the National Correct Coding Initiative Edits web page.

  25. Are there any documentation guidelines/expectations for split/shared services in the hospital? For example, will both providers need to document time separately, or does only one provider need to document for both? Will they both have to document their portion of E/M and time separately in the medical record?

    Answer: There was no change to documentation requirements, every practitioner that is providing services should be documenting in the medical record what they are doing and it should be a complete detail of what is being done to the patient. A complete picture of what was done has to be documented.

  26. Can a cardiologist bill modifier 25 if a procedure is done at each visit? Example: patient is seen for office visit and stress echo, add modifier 25. Then, the patient comes back weeks later and a nuclear stress test is needed and performed. Can we add modifier 25 again for this visit? The doctor has an office visit with every procedure done. 

    Answer: Modifier 25 is for a significant separately identifiable service in relation to the global surgery package, so modifier 25 is added to the E/M code that is performed on the same day as the minor surgical procedure that has a significantly separate identifiable E/M service performed. In the example of a stress echo, this is not a surgical procedure so the 25 modifier would not be valid. It is just indicating the E/M is not related to the surgical service and the applicable allowance that has been added to the surgical procedure for any evaluation type services that go along with providing or performing that surgical procedure. 

  27. The in-person mental health visit is required only after the PHE, is that correct?

    ​​​​​​​Answer: No, CMS said this was effective 1/1/2022.

  28. Please clarify, provider based clinic associated with a critical access hospital can bill split/shared?

    ​​​Answer: If you are billing that as a clinic service to Medicare Part B, with POS 11, split/shared will not apply. If it is billed in the outpatient clinic and billed to Part A under your regular billing cycle with POS 22 or indicate it is done in the outpatient hospital setting, split/share will apply.

  29. Though the split/shared policy does not apply in the office, can established patient visits provided in part by a physician and a qualified health plan be reported by a physician?

    Answer: If there is an incident-to scenario and someone is working as an auxiliary personnel under the physician, and you meet the guidelines of incident-to services then those services can be billed. 

  30. Is there a modifier for a licensed clinical social worker to provide 90834 in-person at the patient's residence?

    ​​​​​​​Answer: There is no specific modifier for LCSW billing. If a social worker is allowed to bill a procedure code and it can be done in the patient’s home, then you bill it as you normally would, using the home place of service. 

  31. Is international normalized ratio monitoring outpatient considered high risk in MDM as monitoring for toxicity?

    Answer: The physician will determine level of risk. There is no hard-fast rule or guidance that can be published to say this is high risk or medium risk. 

  32. Follow up from the G0444 question. The provider must spend at least eight minutes with the patient on depression and document time in order to bill the G0444 screening code. Please confirm.

    ​​​​​​​Answer: The provider must spend at least eight minutes and document the time in order to bill that screening code. CMS’ interactive preventive care services will provide you with that information as well.

  33. When an MD and an advanced practice provider see a patient in the office setting, what are the rules for billing?

    Answer: If you are in an office setting, you would look to the incident-to rules. CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60 talks about incident-to services. You would have to follow the policy to see if that applies or is appropriate for billing.

  34. Is the FT modifier used by any provider performing critical care or just the provider who performed the surgery and is now performing critical care for another reason?

    Answer: The modifier will be used on the critical care service. The critical care is what is being provided within the global surgery period, that is the procedure that will deny without the modifier. You will need to have that on the claim for the critical care service. 

  35. Can you clarify the POS 22 question as that is an on-campus hospital clinic, it is an office but it is an institutional setting (hospital-based)?

    Answer: That is a split/shared scenario. It is place of service 22. Split/shared is not a valid policy for office-based services which is place of service 11. 

  36. If a critical care provider is working with a student, can the provider attest to the critical care interventions documented by the student so as long as the attestation supports the key, critical care and MDM portions were performed by the teaching physician?

    Answer: If you are in a teaching facility and teaching physician setting, the teaching physician will oversee the resident services. A “student” would not be applicable in this situation. 

  37. Could you please confirm whether split/shared visits can be billed in the office of a hospital based clinic (POS 22)?
    Answer: If you are billing POS 22 and that patient is registered as outpatient in the hospital, then split/share would apply. 

  38. I need to clarify something you said. For split/shared, we have never allowed consults to be split/shared regardless of actual code used because Medicare does not allow consult CPT codes. If it is a consult service, it cannot be split/shared is what we educate. I need confirmation that these services can be split/shared now. We have an FAQ from NGS from several years ago that said they could not be split/shared.

    Answer: That is correct, I was focusing more on the setting and not the service. Apologies for the oversight.

  39. Does CMS have a list of what POS can be split/shared?

    Answer: No, CMS does not offer a listing indicating what places of service that split/shared can be performed. The guideline is titled split/shared E/M visits so they would have to be E/M services.

  40. In regard to SUD - the final rule stated: CMS finalized that there would need to be an in-person visit within six months of any telehealth service furnished for the diagnosis, evaluation, or treatment of mental health disorders (other than for treatment of a diagnosed SUD or co-occurring mental health disorder), based on the Final Rule due to lack of mental health providers I thought this was exempt from the requirements for SUD and co-occurring diagnoses.

    ​​​​​​​Answer: The Final Rule indicates that SUD services are mental health.  CR12519 establishes the parameter for in person visits for all mental health services. There is nothing in the CR, the Final Rule, or the Consolidated Appropriations Act of 2021, Section 123 that states SUD services are exempt from this requirement.

  41. Clinic services provided in provider-based clinic setting bill as a hospital outpatient with POS of 22 for the professional services. For split/shared provided in those provider based billing clinic locations would we not apply the modifier?

    Yes, if you are billing as a split/shared service, use that modifier. 

  42. Does an assistant surgeon follow the global period of the primary surgeon (i.e. 90 days) even though the assistant received a reduced payment rate? The follow-up is related.

    Answer: The global surgery fee applies to the physician that is performing the surgery, it does not apply to the assistant at surgery. The assistant surgery would not be bound to the billing requirements, but a key piece is what the assistant is doing during versus follow-up. It could be questioned on an auditing situation and is it to circumvent the global surgery policy.

  43. Is "audio only" telemedicine limited to patient preference or limited access to audio visual in 2022 for all telemedicine services or just mental health?

    ​​​​​​​Answer: That is just for mental health services, according to the final rule. During the public health emergency, there are services that can be performed audio only. 

  44. Do you have a timeline for posting the new critical care guidelines on the NGS website?
    Answer: CMS’ guidelines are posted on the CMS website. MLN Matters® MM12519 Revised: Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List and Preventive Services List is available on CMS’ and NGS’ websites.

  45. Is it required that both providers indicate the time they spent in the medical record? 

    Answer: It is required for both providers to document the services they are performing in a split/shared environment. This is always the requirement for any service performed, you must document everything that is done and who is doing it. Time must be documented if you are billing based on time. Outside of that, the record would show who was doing what and that would lend itself to who the substantive provider is in the case. Also, the provider that performed the substantive portion of the visit must sign and date the medical record. Also, please remember that modifier FS is billed to indicate the service was split/shared.

  46. Does the billing provider have to perform 100% of the key component history, exam or plan) in order to bill?

    Answer: For 2022 CMS has defined: “the substantive portion can be history, physical exam, medical decision making, or more than half of the total time (except for critical care, which must be more than half of the total time.” The final rule further explains that the provider only need perform one of the three components in CY22 to be considered substantive.

  47. What are the telehealth new place of service 10 effective dates and medical documentation criteria?

    ​​​​​​​Answer: CMS released CR12427 and MLN Matters® MM12427: New/Modifications to the Place of Service (POS) Codes For Telehealth which indicates POS 10 for telehealth provided in patient’s home with an effective date of 1/1/2022 and an implementation date of 4/1/2022. This means the POS will not be added until April, but is valid in January. However, keep in mind that CMS has also indicated in this change request that Medicare has not identified a need for the new POS code. CMS has indicated for providers to continue using the Medicare billing instructions for telehealth claims published in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190 as well as any PHE instructions.

  48. For video visits patient verbal consent requirements, what has to be documented in the patient encounter notes?

    Answer: The notes must document that the patient was asked if they provide consent and their verbal consent documented.

  49. Is there a new updated MLN or NCD for acupuncture services for lower back pain with covered diagnosis codes? New ICD-10 code M54.50 – lower back pain, unspecified is getting denied by Medicare.

    ​​​​​​​Answer:  ICD-10 code M54.50 is not payable for acupuncture according to the NCD 30.3.3. Until such a time that CMS determines it is payable and updates the NCD ICD-10 codes that are allowed to include this code it will continue to deny. A list of payable ICD-10 codes may be found with CR11755: National Coverage Determination (NCD 30.3.3) Acupuncture for Chronic Low Back Pain issued 8/27/2020. CMS updated coverage with CR12279: International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--October 2021 issued 5/21/2021 to delete M54.5 from that list for coverage. 

  50. Should we expect increase in medical documentation requests for critical care codes due to new 2022 rules around these codes?

    Answer: Documentation requests are requested for services that are being audited by NGS, or another medical review contractor and will only be requested if a specific service is identified for audit. Just having a new code or new policy information does not make a service identified for audit.

  51. Can nurse practitioners bill 90792 (psychiatric diagnostic evaluation with medical services) or do they have to use 90791 (psychiatric diagnostic evaluation)?

    Answer: A nurse practitioner may bill 90791 or 90792 as long as it is in their scope of practice.

  52. Regarding split or shared visits for 2022, can you define "substantive portion" of history, exam or medical decision making? Would substantive mean documenting one or more of the key components in its entirety? Would this be the same whether the setting is outpatient/office or inpatient hospital?

    Answer: For 2022 split/shared visits, substantive portion is defined as history, physical exam, medical decision-making, or more than half the total time (except for critical care, which must be more than half of the total time). This information was published in CR12519: Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List issued 11/16/2021 by CMS. Also, please remember that modifier FS is billed to indicate the service was split/shared.

  53. Regarding teaching physician services, will the guidelines for these services be effective as of 1/1/2022 or when the PHE ends? Will residents working under the primary care exception continue to be able to bill for all levels of service during the PHE?

    ​​​​​​​Answer: The teaching physician revisions outlined in CY 2022 Physician Fee Schedule Final Rule will be effective 1/1/2022. These changes have nothing to do with any of the waivers for the PHE. Primary care exception will continue to include all levels of E/M billing for the resident. Once the PHE ends, the CMS waiver that allows residents to perform level 4 and 5 E/M services for primary care exception will no longer be in place.

  54. We would appreciate it if the unlisted procedures topic can be added to the discussion list for the teleconference scheduled to 12/2/2021. Areas we need the guidance on are; claim submission requirements, medical documentation requirements, and reimbursement rate: percent based, comparison code based, etc. The CPT guidelines instruct physicians and coders not to select a CPT code that merely approximates the service provided. Also, the guideline states if no such procedure or service exists, then the appropriate unlisted procedure or service code is to be reported. In most cases the services performed are above and beyond the CPT described in the guideline (comparison CPT). Therefore, the reimbursement rate expected is higher than the one set for the comparison code.

    Answer: CPT guidelines do instruct coders to not select a code that approximates the service provided. It is also not appropriate from a medical compliance standpoint because the documentation will not support the code billed. If the service provided is more than what the code describes that would be under coding and that would have potential for not only Comprehensive Error Rate Testing​​​​​​ errors, but audit findings all the way to the Office of Inspector General. 
    ​​​​​​If you are providing a service and there is not a code that fits that service then you bill the not otherwise classified or not elsewhere classified code for that category of service. When the claim is submitted with that code you would indicate in the submission what the comparison code is and what was done beyond that comparison code and that documentation is available. When the claim is reviewed by medical review they will review all the data and most likely seek Contractor Medical Director insight on the procedure and the amount of additional payment, if the procedure meets medical necessity.

  55. Should the date of service be the date of the test or the date of the interpretation for the 24 hour ambulatory blood pressure monitoring, code 93784?

    ​​​​​​​Answer: CMS has indicated in MLN Matters® SE17023: Guidance on Coding and Billing Date of Service on Professional Claims that monitoring services over a 24 or 48 hour, or 30 day period would have the date of service reported based on the description of the procedure code and time listed. “When the service includes a physician review and/or interpretation and report, the date of service is the date the physician completes the activity.” CPT 93784 includes interpretation and report so this would indicate the proper billing for the date of service as after the recording has been complete and the physician interprets and reports the findings.

  56. We would appreciate it if telehealth and modifier 95 can be added to the discussion list for the teleconference scheduled to 12/2/21. During Medicare’s virtual conference which took place on 11/09 and 11/10, a slide showed for telehealth services to bill with mod 95. However, we think that this is indeed not the case. Telephone services, the fact that they are over the phone should imply that the service is a telehealth service.

    Answer: See question number 5 on CMS’ COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing document, which states “During the PHE, the CPT telehealth modifier, modifier 95, should be applied to claim lines that describe services furnished via telehealth.” Since the telephone services are on the telehealth listing then the CMS instruction is modifier 95 should be billed with the service submitted. 

  57. Do the advanced care planning codes 99495 and 99496 have to be provided by a physician or advanced practice provider or can these services be performed by an RN?

    Answer: MLN® Fact Sheet: Advance Care Planning indicates that advance care planning is a face-to-face service between a Medicare physician (or other qualified health care professional) and patient. This means the service is provided by a physician or nonphysician practitioner that can enroll and bill Medicare. It may not be provided by an RN.

  58. When an RN performs an annual wellness visit, can the RN also perform the advance care planning service and bill for both services?

    Answer: An RN cannot bill Medicare for any services, they are not able to enroll as a Medicare provider. An RN may work as part of the medical team under a physician or other qualified health care professional in providing portions of the annual wellness visit, but they cannot bill Medicare for their service.  As mentioned previously, the RN cannot perform the advance care planning service.

  59. If the advance care planning service must be performed by the provider, can the RN perform part of the service, such as helping the patient fill out forms or helping with education, and have the RN’s time count towards the 99495?

    Answer: No, the definition of the code for this service as well as previously stated Medicare policy indicates this service is performed entirely by the physician or other qualified health care professional; not an RN.

  60. Can we discuss parts of the 2022 PFS Final Rule specifically the split shared visits and critical care sections of the final rule please? For 2022, CMS has used the substantive portion of the visit will be the determining factor for the billing provider. Define “substantive” please. Will NGS allow the one year transition to allow “substantive” to mean a key component or time for 2022? How will this need to be documented in the provider’s note to satisfy the key component requirements for “substantive” portion of the visit?

    Answer: For 2022 split/shared visits substantive portion is defined as history, physical exam, medical decision-making, or more than half the total time (except for critical care, which must be more than half of the total time). This information was published in CR12519: Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List issued 11/16/2021 by CMS. Also, please remember that modifier FS is billed to indicate the service was split/shared.

  61. In the Final Rule for critical care services I see two different areas that mention time for critical care services. In one of the areas the critical care add-on code would start at 75 minutes and another area of the final rule mentions the add-on code would start 30 minutes after the initial code time ended meaning 74 + 30 minutes. The add-on code would start at 105 minutes. Does 99292 start at 75 minutes or 104 minutes for CY 2022?

    Answer: Critical care time must be complete in order to bill Medicare. If you have provided more than 74 minutes of critical care then you would have to provide an extra 30 minutes to bill one unit 99292 and so on. Medicare does not allow partial time parameters for billing of critical care.

  62. Can separate data points be assigned if provider reviews unique test results AND unique notes from external physician/specialty? Example: Primary care physician  performs a preoperative clearance on a patient. PCP reviews one lab test result and one electrocardiogram result ordered by cardiology and in addition also reviews notes from cardiology. We assign two data points for review of lab test and EKG under “review of the result(s) of each unique test” and one data point under “review of prior external note(s) from each unique source.” Total three points. Is this correct?

    ​​​​​​​Answer: Based on the scenario provided the EKG was ordered by cardiology and their notes are being reviewed. It would be assumed those results include the EKG so there would not be separate credit given for both. In this information there is credit for reviewing the preoperative clearance information and the notes from cardiology. 

  63. If a provider reviews the results of a unique test ordered by an external physician during a face-to-face visit, should they get credit for review at every encounter for the same test result reviewed? Example: PCP reviews patients past lab results (prothrombin) ordered by cardiology during face-to- face encounter on 12/1/2021. PCP gets one data point under Category 1 for “review of the result of each unique test.” The patient visits her PCP again on 9/1/2022. PCP reviews the same test result (prothrombin) ordered by cardiology. Should PCP get a review data point for “review of the result of each unique test” for the date of service?

    Answer: No, a provider does not get credit for reviewing the same test result at multiple visits. They may receive credit toward that MDM category the first time they review that data.

  64. Can you please confirm when the requirement begins to apply that patients receiving mental telehealth service must have an in-person visit six months prior to the telehealth visit and every 12 months thereafter as finalized in the rule? Current PHE waivers allow mental telehealth in the home without conditions. Is it correct that the rule would be effective January 1 but would not apply until on or after the PHE expires in alignment with Section 123 of the Consolidated Appropriations Act? If not, how do we interpret pg. 158/159 Section 123(a) of Division CC of the CAA amended section 1834(m)(7)(A) of the Act to broaden the scope of services for which the geographic restrictions under section 1834(m)(4)(C)(i) of the Act do not apply and for which the patient’s home is a permissible originating site to include telehealth services furnished for the purpose of diagnosis, evaluation, or treatment of a mental health disorder, effective for services furnished on or after the end of the PHE for COVID-19.

    ​​​​​​​Answer: The requirement for an in person visit six months prior and every 12 months thereafter has nothing to do with a service being rendered in the patient home. This is a new Congressional requirement for providing mental health services via telehealth and will be effective for services 1/1/2022 and after. Please review CR12519: Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List for the information pertaining to this and indicating that this is effective for CY2022.

  65. In a January HCPCS file CMS released a new modifier FQ for audio-only services. Can you please clarify when the modifier FQ for audio-only mental telehealth will begin to apply? My understanding is that currently audio-only telehealth is allowed for behavioral health services per a waiver during the PHE. Can you clarify if CMS is looking for this modifier on claims beginning 1/1/2022 or is this modifier also not required until the PHE expires?

    Page 179 of the Federal Register; after consideration of public comments, we are finalizing as proposed creation of a service-level modifier for use to identify mental health telehealth services furnished to a beneficiary in their home using audio-only communications technology. Page 170; therefore, for certain services furnished during the PHE for COVID-19, we make payment for these telehealth services when they are furnished using audio-only communications technology. Emergency waiver authority is no longer available after the PHE for COVID-19 ends, and telehealth services will again be subject to all statutory and regulatory requirements.

    Given these considerations, we now believe that it will be appropriate to revisit our regulatory definition of “interactive telecommunications system” beyond the circumstances of the PHE to allow for the inclusion of audio-only services under certain circumstances. We believe this proposal is consistent with the expansion of at-home access to mental health telehealth services in section 1834(m)(7) of the Act, as amended by section 123 of the CAA, which required that the beneficiary must have received a Medicare-paid (or payable), in-person item or service from the physician or practitioner furnishing the mental health services through telehealth within 6 months of the first mental health telehealth service.

    Answer: CMS has not provided guidance on the appropriate modifier that will be used for audio only telehealth to this point. Once issued, CMS will clarify this information via the Change Request when/if one is issued. 

  66. ​​​The federal register stated “we are finalizing as proposed that, for services furnished beginning in CY 2022, we will require a modifier to be reported on the claim to identify split (or shared) visits as such”. In this final rule, we are clarifying that Medicare does not pay for partial E/M visits, and that the modifier identified by CPT for purposes of reporting partial services (modifier –52 (reduced services)) cannot be used to report partial E/M visits, including any partial services furnished as split (or shared) visits.” Will there be a required modifier to report split/shared services effective 1/1/2022? If so, can you please provide us with the required modifier to share with our physicians/NPs?

    Answer: CMS has announced the modifier to be billed to identify a split/shared service is FS. 

  67. My question is in regards to the Modifier 52 Claim Submission Billing Reminder article: Modifiers - National Government Services has found that on many occasions, providers are billing for reduced services with modifier 52 appended to the CPT code; however, they are billing the regular charged amount for the procedure. In some of these cases this type of billing could lead to an overpayment.  

    Per CMS IOM 100-04, Chapter 12, 20.4.6: - Payment Due to Unusual Circumstances (Modifiers “-22” and “-52”) (Rev. 1, 10-01-03) B3-15028 the fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. Thus, A/B MACs (B) may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation. The use of modifier -52 indicates that the service is reduced and that the records should be reviewed to determine payment.

    ​​​​​​​As indicated by CMS, the MAC is instructed to decrease payment based only upon review, so it is unclear how the charge would affect payment as stated in the NGS article. Also, if a provider has never submitted that particular code without the modifier, how is it determined that the price submitted has been reduced or not from their regular charge? Will NGS consider updating this guidance to remove the requirement of changing the amount? If not, can you please provide CMS references to support NGS’ request to reduce the charged amount?

    Answer: If you are not providing a complete service then the typical charge for that service is not appropriate for the billing of the service. The charge is to be reduced when a 52 modifier is billed because the complete service is not being performed. There is not a CMS reference on the matter as it is not compliant to bill a reduced procedure at the same amount you would bill the complete procedure.

  68. When submitting a CMS-1500 form if the POS on the form (box 24 B) is correct; however, the address location on the form (box 32) is incorrect, does a corrected claim need to be submitted?

    Answer: You would not submit a corrected claim to change a field. The claim has been processed to adjudication so you would need to submit a reopening or appeal request depending on the situation. If Item 32 does not match the POS then that is an inappropriate claim and would need to be corrected. 

  69. In regard to question ‘When NPPs are employed by several different specialty groups in a multi-specialty practice, what are the rules for “new patient” billing? ​​Answer: NPs are designated by CMS as specialty 50, regardless of the subspecialty area in which they practice. PAs are designated as specialty 97, and the same rule applies. CMS editing only permits one new visit per provider specialty type within a group over a three-year period. Since these are two different provider designations (spec 50 vs. spec 97), new visits by each within a three-year period may be payable. However, if the patient was seen in a multi-specialty practice as a new patient by a spec 50 working within IM, and then seen within three years by a spec 50 working within cardiology, the second new visit would be denied. If documentation submitted on appeal supported a medically necessary service addressing a distinctly separate problem, the second service may be payable on appeal. Updated 6/9/2017.’ Is this information still correct from 6/9/2017? Would the response be the same for when a provider see a patient from another specialty group and a NP then sees the same patient in their specialty?

    Answer: The information is accurate for multiple NPs under a large group umbrella with multiple specialties. It would not apply if the other provider is not an NP. 

  70. On the 5/12/2021 ACT call it was said on a discharge summary for time greater than 30 minutes, CPT code 99239, the exact number of minutes is required. This FAQ is no longer published on your website. Is this still a correct statement? For example, a provider would need to write time spent 37 minutes or is greater than 30 minutes acceptable? 

    ​​​​​​​Answer: Time-based code documentation calls for the amount of time spent performing services to be documented. A general statement, such as more than 30 minutes, is not appropriate. 

  71. Can a discharge summary be done by a resident when the teaching physician attests to the note?  Example of the attestation could say: I have reviewed the notes, assessments performed by the resident, and I agree with the documentation. The patient was seen and evaluated independently with the resident. The teaching physician was present during the key management of the patient.  Patient expressed full understanding.

    ​​​​​​​Answer: No, the discharge summary is to be done the attending physician of record. See CMS IOM Publication 100-4, Medicare Claims Processing Manual, Chapter 12, Section A resident is not an attending physician.

  72. I was wondering if there has been a decision regarding the final rule for split/share visits yet? Would this only apply to hospital only as incident to would be office-based?

    Answer: The 2022 Physician Fee Schedule Final Rule and CR 12519 issued by CMS 11/16/2021 both indicate that split/shared visits only apply to institutional based services and does not apply in an office practice setting.

  73. Can you please clarify how the 2022 split (or shared) visit guidelines will impact joint visits in the office setting (POS 11), where both a physician and NPP see the patient? Specifically for established patients, if an NPP sees the patient for a new or worsening problem, and the physician also sees this patient, who would the visit be billed under, since “incident to” is not met? Also, does this negate the split/shared guidelines for office visits published by the American Medical Assocation, which do allow for split (or shared) visits in the office setting, based on sum of total unique time by the physician and NPP?

    Reference: CMS Physician Final Rule, pg. 425: We believed that limiting the definition of split (or shared) visits to include only E/M visits in institutional settings, for which “incident to” payment is not available, would allow for improved clarity, and clearly distinguish, the policies applicable to split (or shared) visits, from the policies applicable to services furnished incident to the professional services of a physician.  We did not see a need for split (or shared) visit billing in the office setting, because the “incident to” regulations govern situations where an NPP works with a physician who bills for the visit, rather than billing under the NPP’s own provider number. 

    ​​​​​​​Answer: Split/shared visit guidelines will not impact any visit in the office setting as it does not apply in those cases. If an incident to scenario is taking place then you may bill the service as incident to. If an NP is seeing a patient and asks for guidance and/or clarification from a physician on staff that is not a joint or shared visit. If the NP is doing the work that defines the CPT code for that visit then they are the performing provider. CMS has established these guidelines for split/shared visits and they apply to Medicare services. This would negate any CPT guidelines on the subject as CMS has published their own policy.

  74. For split (or shared) visits based on substantive time, how should time be documented in the medical record? Do both the NPP and physician have to document their total time in exact minutes, with the provider whose time is substantive (more than half) being the billing provider?

    ​​​​​​​Answer: Documentation requirements have always been that the practitioner providing services should be documenting what they are seeing, doing, testing and interpreting for the patient visit. It is the expectation that the documentation will clearly identify who is performing the substantive amount of work whether that is through time indication or the work performed by each individual.

  75. CMS has finalized the proposal to adapt the CPT definition of critical care services. Does this change the guidelines regarding billing for critical care? Specifically, previously CMS has said that it is both the complexity of illness and intensity of service (i.e., interventions provided) that allows for critical care services to be reported. Do you still need critical interventions to be performed during the encounter for critical care services to be reported?

    Answer: The previous CMS policy for critical care was removed from the IOM in early 2021 and has been replaced by the policy presented in the 2022 Final Rule and further communicated in CR12519. Critical care by definition is still providing care for a patient that is critically ill or injured. This is further defined as one or more vital organ systems such there is a high probability of imminent or life threatening deterioration in the patient’s condition. This is described on page 32 of the 2022 CPT and does not differ from previous CMS policy for billing critical care.

  76. Are all of the new modifiers FQ (audio only service), FR (two-way a/v direct supervision), FS (split or shared E/M visit) and FT (separate unrelated E/M) required starting 2022? Are modifier FQ and FR only for mental health claims?

    Answer: CMS has not issued finalized guidance on the use of FQ or FR modifiers to date. FS and FT have been indicated to be effective 1/1/2022.

  77. An interventional cardiologist and an electrophysiologist work simultaneously to perform a watchman procedure (CPT 33340-62) as co-surgeons. How much of the procedure does each surgeon need to document? Can one surgeon document the entire detailed procedure note indicating the co-surgeon’s name and the co-surgeon document that he or she participated in the procedure simultaneously? The procedure allows co-surgeons as long as the two specialty requirement is met. If unacceptable, what documentation would be acceptable?

    Answer: Co-surgery is defined as two surgeons in different specialties that are required to perform two parts of the procedure simultaneously. It would be expected that both physicians are providing an operative note to address what they have performed. It is not appropriate for one physician to document the work of another physician. Each physician is responsible for documenting their work they have performed. 

  78. Is it acceptable for the assistant surgeon to document an operative note as long as it was verified and signed by the primary surgeon, the documentation clearly details what the assistant did and that he or she was needed because a qualified resident was not available (we are a teaching hospital)? Assume the CPT code for the procedure will allow an assistant surgeon.

    Answer: In relation to the assistant surgeon, your scenario indicated would be appropriate.

The call was closed. We thanked the attendees for their participation and informed the group that the next Ask-the-Contractor Teleconference would be held in March, 2022 and that the event summary would be posted to our website.

​​​​​​​Posted 1/4/2022