12/1/2022: JK and J6 Medicare Part B Ask-the-Contractor Teleconference Event Summary

Event Summary

Gail Toussaint welcomed 141 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 informed attendees of the handouts provided in the GoToWebinar control panel, and discussed a few topics.

Attendees were advised we are holding a Preventive Services Virtual Conference from 12/6–12/8/2022. Registration is available on our website.

Nathan provided a brief overview of 2023 final rule changes. Regarding telehealth services – the CMS updated the telehealth services listing due to the Consolidated Appropriations Act, policies continuing through 151 days after the PHE declaration ends. For some services on a category 3 basis, CMS has indicated the through date. There are other services added due to waivers or action from Congress, Nathan stressed the importance of reviewing the listing to know what can and cannot be billed. The POS code has not changed at this time, continue to bill using the POS as if you met with the patient in person, along with the 95 modifier. The facility fee has been revised for 2023 as well.

E/M visits for 2023 will bring about continued changes that started in 2021 with office/outpatient services. Changes to inpatient and observation services, emergency services, nursing facility services and home and resident services. There have also been changes to the cognitive impairment assessment within the procedures definition for the service and time alteration as well as allowance changes. Make sure you are looking at the new codes and how they are broken out. There is no longer a separate category for each separate instance, inpatient and observation are in one category so you do not have separate codes for those services any longer. Emergency department changes include 99281 making it more equal to 99211 for office services performed by staff performing services under supervision of clinical staff. Split/shared visits will continue through 2023 with what was implemented in 2022, the substantive portion will be the provider who provided the history or physical exam or MDM or more than half of total practitioner time if time is used as the means for the selection of that code.

For colorectal cancer screening, 45 years is the new minimum age requirement and there’s a change in the reduction of the coinsurance for some colorectal cancer screenings when the patient has a test showing some concern.

Regarding audiology services for 2023, CMS is allowing patients to go to an audiologist once per year without an order from a physician. Modifier AB is part of this benefit. Be sure to check this information out.

General behavioral health integration codes have been added that can be performed by clinical psychologists or clinical social workers (G0323), expanding the benefit. A few codes were added for chronic pain management under the care management umbrella.

CMS is looking at skin substitutes – they will change the nomenclature of the terminology to wound care management products. CMS will hold a listening session in the spring for providers to attend and provide feedback.

You should have received your Medicare participating postcard that came out for 2023. This information is also available on our website and includes provider enrollment resources, Medicare electronic enrollment via PECOS, and other information.

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

99236 same day admit/discharge day service code is listed as 85 minutes in the CPT code book. In the final rule, 99236 is listed as 95 minutes. Will Medicare require a different length of time to be used for this code than CPT in 2023?

Answer: CMS did address this in the final rule, however, if there will be a different time amount required, it would be addressed in a change request of which we have not yet received.
Is it appropriate to give credit under presenting problem for an undiagnosed new problem when they truly do not know what the problem is but it may, or may not, potentially be a high risk scenario like cancer or appendicitis? Also, can you give us clarification on the true definition of an undiagnosed new problem with uncertain prognosis?

Answer: If the patient is coming in with an undiagnosed condition, then you are dealing with signs and symptoms to see if there is something additional going on with the patient. Sometimes those independent signs and symptoms are just that. Sometimes they are together indicating a bigger issue, so until that diagnosis has been made, it will be an undiagnosed new problem for the patient.
Two-part question for billing continuous glucose monitoring: CPT Code 95250: (Part 1) What date of service should be reported on the claim? The full code description indicates “for a minimum of 72 hours” and (Part 2) does the removal of the sensor and printout of the recording have to be done as part of a face-to-face encounter, or can it be done by the patient at home with proper instructions? If the latter, can this code be billed, and should it be billed with a modifier?

Answer: To answer Part 2 first, if you’re billing a CPT code for removal of the sensors and printing the data, and the patient is doing that, you don’t have a service to bill. For 95250, minimum of 72 hours, the DOS will be when the service was provided, when it began. You won’t know if they lasted a minimum of 72 hours until 72 hours have passed. You wouldn’t want to bill today’s date of service today, and then have the patient have some kind of issue, and the machine comes off tomorrow, because then you’d be misreporting a procedure code. You can bill the date it was hooked up but it does have to meet the requirement of the code to meet that 72 hours.
Per the AMA CPT Changes for 2023, the guideline states two E/M services can be billed on the same date with modifier 25. For example: Patient presents to office, MD provides E/M service (99214), sends patient to be admitted to inpatient, provides the hospital admission/or observation admission service. Can the MD report 99214 – with modifier 25 and the admission to inpatient/observation same date of service? Please clarify if CMS is following the AMA guidelines.

Answer: No, this is one area where CMS is not following AMA guidelines. The AMA is aware of this and they have had discussions with CMS about it. Medicare policy does still apply for not having two E/M services on the same day, and that same physician cannot bill separately for both services.
In the complexity of data to be reviewed and analyzed section of the medical decision making table, if a provider orders an echocardiogram and then speaks to the cardiologist about the interpretation and that discussion is noted, I understand credit can be given for discussion of a test with another QHP (category 3), but can credit be given for the order as well in category 1?

Answer: If a physician is ordering the echocardiogram, and the cardiologist is reading it, and then they are discussing that, there will be no additional credit given for that discussion along with the order.
Can you clarify if a MD is continuing the same medication, does this qualify for prescription drug management? If a provider reviews and determines the patient needs to continue the medication same dose, does this constitute prescription drug management or does the script have to change the dose in order to fall under the moderate table of risk?

Answer: Prescription drug management means that the physician is fully evaluating the prescription the patient is on. They are looking at side effects that may be taking place, or how effective it is. Prescription drug management is looking at all of these things to determine that its working and they are keeping it the way it is. The key is, there has to be some level of evaluation of the prescription drug usage to see if it’s working or not working. Calling in and requesting a refill of a script and writing a new script is not prescription drug management.
Would the following scenario be considered acceptable substantive documentation for the MD to bill? Patient initially seen by the NPP who documents the medically appropriate history and exam and notes an Assessment/Plan (A/P). The APP then discusses the case with the MD who concurs with the MDM but wants to add an additional medication or test. The MD then adds "I participated in a shared visit with the NP and have reviewed the history, exam and A/P." The MD copies the A/P documented by the NP and adds the additional prescription or testing. Will this suffice as the substantive portion?

Answer: No, the physician is not really providing MDM, they are just tweaking what the NPP has already done. The NPP performed the history, exam and the MDM. The physician is just reviewing the case with the nonphysician, so that does not constitute substantive work that the physician is doing in order to bill the service under them.
When symptomatic potential COVID-19 patients are being tested in a parking lot prior to entering a clinic, what POS would NGS expect to have reported on the claim for that service? Would a POS of 10 ever be appropriate?

Answer: No, POS 10 is referring to the patient’s home so that would not apply. When you are testing in the parking lot of the physician’s office, it will be the physician’s office POS.
If the clinician recommends a diagnostic test or treatment based on the risk/benefit analysis, but the patient declines the test or treatment, it is still counted in the MDM data scoring for their level of service?

Answer: Yes, the physician is still doing the MDM. The physician has taken those steps, they have done that work, that’s the medical decision making piece. If the patient doesn’t continue, this will not detract from that at all.
I have a question regarding the new prolonged service codes for inpatient and observation services. AMA and CMS differ between the codes that should be used as well as the time thresholds. Although the code description states “each additional 15 minutes” please confirm that to bill G3016, a full 30 minutes of prolonged services must be performed before that code can be added.

Answer: Yes, that’s correct. Per the final rule, its indicating a full 30 minutes needs to be provided in order to bill G3016. We’re waiting for a change request or specific policy to confirm this but the table 24 references it and provides the detail confirming it.
If a prescription is written for a medication that is available OTC, can the MD get credit for that? For example Motrin 600MG?

Answer: Prescription drug management is for prescription drugs. If it’s available OTC, it’s not considered a prescription drug per CMS or Medicare.
Are stop and start times required for any of the prolonged service G-codes?

Answer: CMS indicated in the IOM start and stop times are required for prolonged services, but that’s the only service they have indicated this is required.
We’re receiving denials on new patient visits that are hitting against telephone visits. I thought I received an email a while back that stated new patient visits wouldn’t be impacted by phone visits because those were not face-to-face. Did something change or was that not the case?

Answer: If the physician had a telephone E/M visit through the PHE, that’s considered an E/M service. Those telephone services are considered professional services. Once you have a telephone visit, they’re no longer considered a new patient, according to the patient guidelines.
Patient presents to urgent care for a sore throat. Three tests are ordered: rapid strep, culture and a COVID-19 test. Antibiotics are prescribed at the end of the visit. Does this support level 4 (moderate MDM) for data and risk?

Answer: Risk is based on the entire evaluation of the patient’s condition, their history and examination, so Medicare cannot tell you whether that’s a certain level of risk. That determination is made by the provider based on the evaluation. The AMA does provide some examples of clear cut scenarios that may provide guidance to you.

Follow-up to Question 14

I understand that it’s not common to say 'yes it's level 3 or level 4' but I asked about two components of medical decision making – data and risk. Prescription drug management is an example provided under moderate risk on the MDM tool. If risk cannot be assigned as it depends on the provider's intuition of the visit, then how, as an auditor, am I supposed to successfully provide feedback to my APPs and MDs? There would be no role for an auditor or any reason to deny a level of service if the answer is only to go by the provider's intuition. What about the data portion of my question? This was completely thrown out as risk was the only thing commented on.

Answer to Follow-up Question 14: While I understand you’re looking for confirmation on if a specific service meets certain criteria for E/M code selection, we as a MAC are not authorized to code for providers or provide coding advice. As mentioned, the level of risk is really up to the treating provider based on the complete history and treatment of the patient. This has been indicated not just by CMS but also by the AMA. As to how to audit these types of services, the MDM table provided by the AMA is a guide to help you follow the record and care of the patient. If the physician is indicating something in the risk for the patient that doesn’t make sense based on their history or previous care that would be a topic to address with the physician. They would need to justify the level of risk with your internal audit just as they would for an outside auditor.

To the additional portion of your question, I would agree that according to the MDM table, ordering three tests would meet a high level as long as they are unique tests. So, if there are three different, distinct tests being performed, then you have made that level. The other piece of that is the unspoken need of medical necessity. Documentation would need to indicate the need for those tests to be ordered. Based on the question with a patient presenting with a sore throat does not give any indication of what was taken into account. Is it just standard practice for a patient presenting with a sore throat to have these tests ordered? If so, that may be considered routine and not based on medical necessity. What additional exam or history has led to the thought process for the need for these tests?

The last piece in regard to antibiotics being prescribed, that would fall under prescription drug management, as long as they are prescription medications and not something provided over-the- counter. Again, the medical record would show the consideration and need for that course of treatment with that medication.
G0444 depression screening, up to 15 minutes, is obviously a time based code. Since it states up to 15 minutes, does time need to be documented at all and if so, does a minimum of 8 minutes need to be documented (the half way point of 15 min)?

Answer: Yes, for time based codes that are not otherwise indicated, in this case it states “up to 15 minutes” CMS follows the AMA’s guidelines that at least half of the time measurement has to be met in order to bill that code. The time does need to be documented in the patient’s medical record.
How many minutes need to be documented for code 99292 to be billable by a provider? Can it be billed after 75 minutes are met? Or does the full 30 minutes after 75 minutes need to be performed for 99292? Does the rule apply only to the shared split visit or all critical care services? When was the effective date of policy?

Answer: It is the full 30 minutes that needs to be met to bill a unit of 99292. This applies to all critical care services. The CMS effective date for this policy was 1/1/2022.
Can a wellness visit/annual wellness visit be done in the SNF or nursing facility?

Answer: Yes, these are allowed to be billed in a nursing home, a SNF or a nursing facility.
In 2023 when a patient is put into observation status (place of service 22) and a consultation is performed by a specialist, would that specialist use codes for outpatient (99202–99205) or inpatient (99221–99223)?

Answer: If there’s a specific, dedicated outpatient observation unit and that’s where the facility indicated the patient is, then they’re considered outpatient. But it’s an observation service, so it’s an observation code. The POS may be outpatient but they are observation services.
Can you provide confirmation that CPT 87637 is the appropriate code to utilize for medically necessary tests performed on the biofire technology, instead of PLA code 0202U?

Answer: No, procedure code 87637 is not appropriate. The CPT code book preamble for the section that contains 0202U states:

Proprietary Laboratory Analyses 0001U–0284U

When a PLA code is available to report a given proprietary laboratory service, that PLA code takes precedence. The service should not be reported with any other CPT code(s) and other CPT code(s) should not be used to report services that may be reported with that specific PLA code. These codes encompass all analytical services required for the analysis (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification, hybridization and detection). For molecular analyses, additional procedures that are required prior to cell lysis (e.g., microdissection [codes 88380 and 88381]) may be reported separately.
If a patient is in the ED and the emergency medicine provider determines the patient needs observation level of care, a note is written and the patient is moved to a separate area of the ED for observation patients, and another emergency medicine provider assumes care. We know that only one E/M provider may submit a bill, but can the billing provider who is billing the initial observation get credit for escalation of hospital care (High MDM) for the determination that the patient required observation level of care?

Answer: If an ED physician determines they need to be put in observation, then they admit them in observation. If another physician takes over that care, they’re not admitting the patient, they’re providing subsequent hospital care. The first physician will get credit for the work they did. They can include services performed in ED visit, but both physicians cannot bill for the same service.
For gastro – is it permissible to require new patients to present to the office for a full evaluation prior to scheduling a screening colonoscopy? More often than not, we find the patient has other issues or concerns that need to be addressed so we’re able to combine multiple studies into the intended screening colonoscopy versus having the patient come back separately. However, there are also times where the patient is fully healthy and there’s no other diagnosis other than the screening colonoscopy for the initial office visit.

Answer: It’s not medically necessary to have a patient come in for an E/M service just to order a colonoscopy. There may be a need to do additional services. You are scheduling a colonoscopy based on the patient’s current condition, and you may need something from their primary care physician because they’ll be screening the patient, they can provide you with that information. If their PCP is recommending a colonoscopy, it doesn’t make it necessary to go through a complete evaluation of the gastrointestinal system in order to allow that order to be fulfilled.
What’s the time-frame for 99358 prolonged visit? Within how many days/months after the associated/related visit?

Answer: 99358 is no longer valid after 1/1/2023. As far as the actual prolonged service time right now, we would follow CPT guidelines. The 2023 final rule indicates those codes are no longer recognized by Medicare.
In the final rule it states, “providers have the option to use the ‘FQ’ or the '93' modifiers or both where appropriate and true, since they are identical in meaning.” When would a provider use both? Can you explain the difference between modifiers FQ and 93?

Answer: The 93 modifier indicates it’s a telehealth service. The FQ modifier is related to mental health services. We don’t know when both would be used together. 93 is not used during the PHE, so that isn’t in place at least until the end of the PHE.
Would an E/M with modifier 25 and shoulder injection be appropriate in this scenario? A patient presents to an orthopedic office for shoulder pain. The provider documents a medically appropriate history and exam, reviews a previous X-ray with the patient, offers OTC pain medication, physical therapy or cortisone injection. The patient opts for the injection. An appropriate procedure note is documented with risks, benefits, injection, disposition and post procedure care. The provider then recommends physical therapy and Tylenol if pain continues. I believe the X-ray review and referral to physical therapy and Tylenol are outside the typical pre and post procedure work.

Answer: Everything described is an evaluation that leads to the injection procedure that’s being done. The evaluation for that is related to that procedure and is part of the allowance for that procedure. There is no billable separate E/M service.
Does Medicare pay for family planning office visits when the diagnosis code is Z30.42 (encounter for surveillance of injectable contraceptive)?

Answer: No. That isn’t something that falls under any Medicare benefit category.
For Medicare patients that are unable to have a video telehealth visit due to no internet, etc. will NGS still reimburse at that level for an audio only telehealth visit?

Answer: If the telehealth listing indicates the service can be provided over the telephone, then yes. If not, meaning audio and video are required, then that is how the service has to be provided or it is not a telehealth service.
At the conclusion of the public health emergency, will LCD open meetings go live or will all meetings be virtual moving forward?

Answer: We do hope to hold in-person meetings in the future, but we’re not there yet.
Is there a list of specific CPT category II (quality reporting codes/nonpayment) that you accept for processing, not payment?

Answer: You can select category II codes to provide clarification or information, but there is no specific list for things that are covered or what specific codes to bill for.
Regarding the CMS final rule for licensed professional counselors as Medicare providers, can you specify the definition of "general supervision?"

Answer: It’s the same definition CMS has provided for general supervision, it means the physician is generally supervising the patient. They don’t have to be in the room or office suite, they’re overseeing the counselor and their work. They have to be available immediately, as necessary, if the counselor needs to speak with them in order to provide input.
For third level of medial branch blocks 64492/64495, the LCD states “Codes 64492 and 64495 will only be covered upon appeal if sufficient documentation of medical necessity is present”. Is that the medical necessity criteria from the LCD or is there some additional criteria for this third level? We usually meet criteria listed in LCD and yet have no luck getting the third level paid.

Answer: It would be based on the LCD. LCDs are put in place to provide coverage guidelines. Documentation would have to show medical necessity.
For 2023, ED provider orders an EKG. Provider is not billing separately for EKG. Can the ED provider count the order and independent interpretation for MDM?

Answer: They can count the order, they have ordered the test, so that’s part of their MDM. Counting an independent interpretation depends on whether someone else interpreted the EKG and they need to do an additional full and complete interpretation because something is off from the interpretation. If that situation exists, yes, they can bill an independent interpretation, but there needs to be some indication in the medical record of why the independent interpretation was needed/necessary.
How would we calculate the review for data for inpatient services? Do providers need to bring all lab and imaging results in note to get credit? Or we can review orders, labs and imaging labs to determine the orders for encounter and the results?

Answer: Documentation needs to show everything the physician is doing and has done during the service. The note needs to be complete. If they’re looking at other lab work, there needs to be an indication of what that was, what the results were, what that means to the physician, what they believe that means for the patient. It’s a complete picture of what is going on with the patient during that evaluation.
In the scenario where the MD orders an echo and then discusses with the cardiologist. Can you opt not to give credit for the order but give credit for the discussion of the test with another MD?

Answer: Yes, you can take credit for one or the other, you just cannot take credit for both.
When after a year of telehealth (new patient video visit), the patient is now seen in the office in person, is this considered an established patient?

Answer: Yes, this is considered an established patient because you had performed services. According to the IOM, they meet the definition as an established patient.
I have a question regarding “independent historian” as a data point for MDM under the 2021 E/M guidelines. Is a parent accompanying a child to a pediatric visit, where the note states “mom is historian” considered acceptable as credit for independent historian? Is there any age requirement? For example: would it be allowed for an infant who cannot speak as well as an older child who can speak, where mom is adding pertinent items to the history?

Answer: The AMA in CPT defines independent historian, and that definition includes parent, so yes, this would be acceptable. If information is received from both mother and child then you may want to indicate who has provided what information as well. Page 11 of 2023 CPT contains the definition and the parameters. There is no established age limit. If there were some need for an independent historian, as indicated in CPT, then it would still be appropriate.
My coworker attended a recent webinar. There was some discussion on incident-to. If the advance practice clinician (NP/PA) sees the patient to monitor their chronic condition incident-to the MD/DO (established patient/established plan of care), would that be acceptable to log that date as the date last seen?

Answer: The information from the article and the IOM reference is correct that a NPP visit does not qualify as the date last seen for podiatric services. CMS has made it clear in their policy indications that the date last seen is a visit the patient had with and MD or DO, not a NPP.
The new E/M rules related to the choice of medical decision making or time to select code level for many E/M codes seem to contradict the split/shared rules related to substantive portion with regard to the history and exam. If the physician’s documentation of the history or exam exceeds that of the NPP, I would think documentation of the MDM would still outweigh what E/M is chosen based on the new E/M guidelines. In 2023 there is no history/exam leveling, it simply states a medically appropriate history/exam.

Answer: There’s no contradiction as these are two separate determinations. First, the determination is made whether the E/M service is to be billed based on MDM or on time. Second, once that determination is made, the practice would determine who provided the substantive work. While history and exam are not utilized in selection of the CPT code for billing, they’re still part of the service, as you indicated. CMS has simply allowed the substantive provider to be whomever has provided any of the components, for another year, to allow providers additional time to adjust to the concept prior to 2024.
Are cooking classes covered under medical nutrition therapy or how can cooking classes be covered under medical nutrition therapy?

Answer: No, cooking classes would not be included in MNT. MNT is therapeutic and counseling to help manage the patient’s condition.
Is moderate sedation code 99152 billable on professional claims when MD documentation states “I have ordered and supervised moderate sedation administered by RN. Patient was monitored for more than 15 minutes”? Services are rendered in inpatient or outpatient location. Is this an instance where service is billable by MD on professional claim based on supervision? Or to bill for 99152 MD must personally administer the moderate sedation drug?

Answer: Note: We’ve updated this answer due to clarification received for the question asked. Yes, that would be appropriate. The AMA when they implemented these new codes in 2017 indicated in the examples that the service is valid when a physician or other qualified healthcare professional, supervises or personally provides the administration of the sedating agent.
Critical Care split/shared guidelines: Please clarify whether we have an option to bill MD and NP critical care services on the same date independently or must we sum their combined time and bill as split/shared under the provider who performed greater than 50% of the time.

Answer: A physician and a nurse practitioner were working in the same group and the same patient that is a split/shared service. All the time for that day is combined into one time and whomever performed more than half of the time is who the service will be billed under.
For 2023, do we need to complete a whole 30 minutes of critical care to report 99292? Or is 99292 billable for any time beyond the initial 74 minutes (i.e., 80, 90, and 104)?

Answer: CMS has clarified in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.4 as well as in the 2023 Physician Fee Schedule Final Rule, that 30 full minutes beyond the 74 minutes of the base code is required to bill 99292.

“Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes).”

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.

Updated 1/23/2023