EM Coding Alert

Finally get clarification on Medicare’s rules for E/M service encounters.

On Aug. 29, 2023, the Centers for Medicare & Medicaid Services (CMS) finally released an updated version of its Medicare Learning Network (MLN) Evaluation and Management Services Guide, which it had withdrawn in February.

Here are three of the big takeaways from the new MLN E/M guide you need to know when billing E/M services for your Medicare patients.

Beware Discrepancy Over Critical Care Prolonged Services

The current MLN E/M guide highlights a major disagreement between CMS and CPT^® over when you can apply +99292 (… each additional 30 minutes (List separately in addition to code for primary service)) to 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) to reflect prolonged critical care services.

CMS tells you to ignore CPT^® instructions to apply +99292 once the provider has met 75 minutes of critical care service time. Instead, the MLN E/M guide instructs that you only apply +99292 when the provider spends 104 minutes (74 + 30 = 104 minutes) or more with the patient.

“This contradicts the AMA’s long-standing rationale for the initial critical care time requirement (99291) and when to apply the additional time code (+99292) threshold,” notes Kelly Loya, CPC, CHC, CPhT, CRMA, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services. In the Time section of the CPT^® code book, the AMA states, “a unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and 60 minutes).” So, “CPT® defined the codes originally to require 99291 to report the first hour and +99292 for each additional 30 minutes. That means two units of +99292 requires 134 minutes, 3 units requires 164 minutes, and so on,” explains Loya.

However, the MLN E/M guide states “the general CPT^® rule about the midpoint for certain timed services doesn’t apply.” In other words, “CMS is requiring providers to meet the full 30 minutes beyond the definition’s maximum time of 74 minutes, plus the full 30 minutes for +99292 (or a total of 104 minutes) to report +99292 with 99291,” Loya adds.

Find Guidance on New CMS Prolonged Service G Codes

At the beginning of 2023, CMS introduced three new prolonged E/M service codes for use with inpatient, observation, nursing facility, home or resident visits, and for cognitive impairment assessment and care planning services. The codes in question are:

• G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) …)
• G0317 (Prolonged nursing facility evaluation and management service(s) …)
• G0318 (Prolonged home or residence evaluation and management service(s) …)

The MLN E/M guide provides clear guidelines for time thresholds and how to count time for each one. For example, you would report one unit of G0316 for any Medicare patient inpatient/observation visit coded with 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. ) when the provider’s visit meets the 90-minute time threshold, since the visit has met the full 15 minutes for G0316.

CPT^® and CMS follow the same threshold for reporting prolonged time with 99223 and 99233 (Subsequent hospital inpatient or observation care, per day …), as the codes include a “must be met or exceeded time” versus a time range (so there is no difference in time threshold calculation based on minimum versus maximum), and time spent can only be counted on the date of service. For non-Medicare patients, the correct code would be +99418 (Prolonged inpatient or observation evaluation and management service(s) time ... each 15 minutes of total time ...).

However, for reporting prolonged time with 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date … When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.), CMS uses pre- and/or post-visit times on other dates for certain services. That gives a total time of 94 minutes for 99236, which is rounded to the nearest five minutes (95 minutes). You would report a single unit of G0316 once 15 minutes beyond this time has been reached (110 minutes).

In this example, the guide also tells you that you can count physician or nonphysician practitioner (NPP) time spent on the service from the day of the service up to three days after the service toward the total time for the service.

Remember: “While these variations can be difficult to keep straight, it is extremely important to stay aware of the time threshold differences between CPT^® and CMS to ensure the appropriate codes are reported with the appropriate units,” cautions Leah Fuller, CPC, COC, senior consultant at Pinnacle Enterprise Risk Consulting Services, Kannapolis, North Carolina.

Double Down on CMS’ E/M Documentation Requirements

The revised MLN E/M guide also attempts to clear up confusion regarding what elements of an E/M service your provider should document.

History and physical exam: This year, the AMA removed the guideline for using specific history and physical examination as elements for selecting the level of all E/M codes that have levels of service. Instead, CPT^® requires such E/M services to “include a medically appropriate history and/or physical examination, when performed” (emphasis added).

But this does not mean that history and/or physical examinations are not required for E/M encounters. Rather, the MLN E/M guide notes both are still an integral component of leveled E/M services even though they are “not an element in selection of the level of these E/M service codes.” The guide also notes that “the treating physician or other qualified health care professional reporting the service [may] determine the nature and extent of the history or physical examination.”

Chief complaint: The 2021 office/outpatient E/M overhaul allowed physicians to “only document that they reviewed and verified information regarding the chief complaint and history that is already recorded by ancillary staff or the patient” (www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management). Again, some took this change to mean the patient’s chief complaint did not have to be documented at all; however, the MLN E/M guide emphatically clarifies that “the medical record should clearly show the [chief complaint] CC,” which should be “a short statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.”