MACtoberfest: Things They Are A'changin' - January 2021 Webinar

Published 01/06/2021

These questions were asked during MACtoberfest’s “Things They Are A’changin’ January 2021” live webinar. Most of them were asked, and answered, in anticipation of the 2021 Final Rule. Please keep in mind that the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule had not been released at the time of the presentation. Palmetto GBA cannot speak to American Medical Association (AMA) publication of a code(s) or descriptions or how another insurance plan may handle the new evaluation and management (E/M) coding. Please refer to the MLN 12071 Final Rule 2021 (PDF, 255 KB), which was released after this presentation, for more definitive information.

Question: As we talk through the E/M changes, I'm interested to hear your expectations for shared service visits. Current requirements indicate a physician must do all of either the history, exam or Medical Decision-Making (MDM), or some of all three elements. With the history and exam no longer applicable for code selection, what is expected by the physician to now meet shared service billing requirements? When billing based on time, how much time would be considered "substantive?" Same for MDM? How much of the MDM?

Answer: Most shared service visits are for inpatient visits and the new changes do not apply. You may be thinking shared visits in the context of incident to visits and they still require a face-to-face physician visit as a first visit and can only be used for visits for an established patient where a care plan has been developed. In that situation, the extender may do the history and exam and the M.D./DO does the medical decision-making that can be billed under the M.D. IND. This issue is under review by the Centers for Medicare & Medicaid Services (CMS), but no additional information has been released.

Question: If a physician sees a patient face-to-face in the office after a telehealth visit is performed prior to the visit on the same day by the physician assistant (PA), are both visits billable?

Answer: Without looking at medical records it is difficult to answer this question as we don't know all the circumstances.

Question: That shared visit question was mine. I understand the medically appropriate history and exam. However, since those elements are no longer considered in selecting a LOS, this doesn't make sense any longer. For time, we would count the history and exam, but what amount of time is expected? One-third?

Answer: The actual time spent is what is billed. No expected time is attached to any function.

Question: For split/shared visits, if a nurse practitioner (NP) sees the patient and the physician reviews the test/labs but does not do a face-to-face can it be billed as split/shared?

Answer: Although the rules are under review, it appears that a face-to-face is still required.

Question: If a provider bills a performs and bills a CPT 93000 diagnostic test during an E/M visit do we credit the provider with ordering this test?

Answer: Time is within the CPT 93000 and should not be billed as part of the E/M.

Question: Please clarify that split/shared is a concept that is usually done inpatient so at this point since those codes are not changing that concept does not apply.

Answer: The new rules only apply to outpatient visits. Split/shared can occur in an outpatient setting, but usually as incident to situations.

Question: If the service is delivered in a provider-based billing setting, will the new changes in E/M be applied?

Answer: The sets of E/M codes that CMS makes changes to will be applicable.

Question: Has CPT code 99211 been deleted?

Answer: No, CPT code 99211 has not been deleted. Additionally, 99211 has no time attached. We apologize for any confusion regarding this during the presentation.

Question: During an audit, would you consider a condition to be managed if it were only linked to lab or medication order from the EMR in the assessment/plan?

Answer: Although it probably would depend on the circumstances, I would doubt it.

Question: Will all insurance plans be using and accepting these prolonged time codes?

Answer: As a Medicare Administrative Contractor (MAC), Palmetto GBA cannot answer for other insurance plans.

Question: Reviewing these updates from AMA, I have found that there is still quite a bit of subjectivity between the level 2 and level 3 E/M levels including no real difference between straightforward versus acute uncomplicated illness or injury. What will Palmetto GBA be looking for to determine the difference between the two levels? Data for level 2 state "minimal or none" versus 1 of 2 categories for level 3. What is minimal?

Answer: The documentation detailing the care will be reviewed to align the codes billed. CMS is reviewing this issue.

Question: Does a parent count as an independent historian in all circumstances if they are speaking for a pediatric patient who developmentally cannot?

Answer: The diagnosis that substantiates the impaired child would assist in determining if they are the permanent historian.

Question: What historic parts of the record is a provider allowed to use and only indicate reviewed? Only their own notes? Anything in the EHR? Is there a timeframe (i.e., within the last 12 months), or everything free game?

Answer: All.

Question: What needs to be documented for social determinants of health? Can we just use diagnosis based on patient report? Or do you have to have some type of proof of food insecurity?

Answer: The better the documentation supports the code billed the more likely the code billed is paid.

Question: If there are more than one unit of a prolonged service needed, is this reported with one charge line and multiple units, or separate charge lines with one unit each?

Answer: Examples give multiple lines.

Question: In the outpatient setting, with a shared visit when using shared time with a physician and PA, do incident to guidelines still have to be met?

Answer: Yes, per current instructions.

Question: Do you have to use a modifier for the extended CPT code after using the 99215?

Answer: I am assuming you are speaking of the prolonged codes in addition to a 99215. No modifier is needed for the add-on code.

Question: How does this affect the observation services in the hospital when the provider is not the admitting physician?

Answer: Currently observation services are billed by the admitting provider. The E/M changes do not apply to the observation codes.

Question: Please clarify regarding patients who are in an observation status in the hospital and seen by a consultant and not the provider who admitted to observation. Current rule is for the consultant to report E/M outpatient codes. Will 2021 E/M changes update this reporting for consultants seeing patients in the observation hospital setting?

Answer: We are not aware of any change.

Question: Would you agree that the current mental health rules for billing will basically remain the same for 2021 since we base our billing primarily on time?

Answer: Mental health visits are unchanged. If the mental health provider is also billing E/M visits, then the new rules apply.

Question: Do these changes apply to behavioral healthcare providers as well?

Answer: Any final E/M coding changes and rules would apply to any provider type that uses E/M codes for billing.


Question: When coding based on time in 2021, what amount of time would be a red flag for total time in a day?

Answer: No specific time; however, using a high level of time consistently and significantly more than your peers may attract attention.

Question: Will scribe time count towards total time of the visit?

Answer: No.

Question: How do residents factor into the documentation and calculation of time for these new E/M CPT codes?

Answer: Residents would factor into the documentation the same as any ancillary personnel or extender under the incident to rules, if applicable.

Question: Will a resident be able to code for time if teaching faculty are not with them for the total duration of time spent with the patient?

Answer: Refer to the 2021 Final Rule.

Question: Does time spent need to be documented in the note?

Answer: If the code is selected based on time, yes.

Question: Is the Medical Decision-Making (MDM) for 2021 the same criteria as the 2020 MDM? Or is it different?

Answer: The MDM criteria has not changed.

Question: Does the E/M have to be billed based on time if the start and stop times are documented in the encounter? Or can MDM be used?

Answer: That is determined by the provider.

Question: If the provider documents time but the MDM provides a higher level of service, would the level be determined by the higher level of support?

Answer: Correct. The provider has a choice of using time or MDM.

Question: Does the documentation have to indicate billing based on time or MDM-driven? And does the coder have to choose the lower to the 2 levels?

Answer: No, but the nature of the note should make it clear what type of visit it is.

Question: Is there a specific guideline for determining MDM?

Answer: There are definitions for the complexity of the visit.

Question: If we are giving an infusion that takes three hours and the physician doesn't administer it, but the nurse does, can we bill an E/M service based on time?

Answer: No.

Question: Pub. 100-04, Chapter 12, Section 30.6.1 C (PDF, 1.10 MB) states that time in conjunction with MDM can be the basis to report a level of visit when counseling and coordination of care dominate the visit. Do you anticipate we will see this guidance changed for 2021 in light of the office visit changes?

Answer: Counselling is included in the time spent for visits. For MDM visits they are not included.

Question: Regarding risk of complications of patient management — does contrast with imaging fall under "Prescription management" or other means of meeting moderate risk?

Answer: Unclear; it depends on the situation and why the order is being rendered

Question: How does the time need to be documented? Per area or overall visit?

Answer: If billing based on time it would be the time for the entire area. Start and stop times are optional and can be included for or the time calculation but are not required.

Question: How is it going to be possible to prove your time spent when it includes MA time with the patient, physician time with the patient, time spent ordering tests, etc.?

Answer: A statement of total time is all that is necessary. Putting  start and stop times would be ideal.

Question: Why would we document start and stop time of the face-to-face encounter when there are other non-face-to-face activities that also count towards the billing time?

Answer: Start and stop times are not required; however, when available, they will provide better documentation of the time spent.

Question: If it is a total time, can you clarify why it was suggested to record start and stop time of the face-to-face?

Answer: If your EHR/EMR doesn't supply a start or stop time, then the gold standard is to document the start and stop times.

Question: Did I hear correctly that we need to document start and end times? Does this include triage checkout? Or just provider time?

Answer: Provider time should be documented so that it is easily identifiable as the provider time used towards selecting a code.

Question: Are there documentation recommendations in regard to time? Or how the MAC expects time to be documented?

Answer: Start and stop times are not required; however, when available, they will provide better documentation of the time spent.

Question: Does the provider need to document just the start and stop times of the face-to-face, or does the provider need to document time spent reviewing and documenting in the record?

Answer: Start and stop times are not required; however, when available, they will provide better documentation of the time spent.

Question: Dr. Garrett mentioned that the total time spent can include the front doing the review of systems (ROS) with the patient, the doctor’s time spent with patient, and then the time doing the note. He mentioned to put beginning and end time in the note. When being audited will these times differentiated be required in the note?

Answer: A statement of total time is all that is necessary. Putting start and stop times would be ideal.

Question: When you use the new prolonged service codes, should we only use the time-based calculation to decide the base E/M?

Answer: Prolonged service only applies to timed E/M billing.

Question: How can you say it is prolonged time if you are not measuring time in the first place to get to a level five?

Answer: Prolonged service only applies to timed E/M billing.

Question: Based on read material, only the physician time, not the clerical time, would be counted in the total time. Recommend reviewing and clarifying.

Answer: Either I misspoke or was misunderstood. Time spent reviewing materials from clinical staff, the review of systems (ROS) FMH, medications, old records, etc., counts. The time spent collecting the information does not count.

Question: Can you clarify time used for selecting an E/M in the teaching setting? In a residency program, can the resident's time (without the teaching physician present) be counted in the total time for selecting the E/M level?

Answer: Please refer to the 2021 Final Rule for any change regarding the reporting of teaching time.

Question: Can resident and physician time be combined for an outpatient visit?

Answer: Review the 2021 Final Rule carefully, paying particular attention to the information for residents.

Question: My understanding is that time spent by ancillary clinical staff is not to be added to the provider time for level support, per AMA. Does this mean that Palmetto GBA will calculate time differently to allow for ancillary clinical time?

Answer: That will depend on whether a face-to-face visit has occurred and to what capacity the ancillary staff is performing the task.

Question: Does aggregating the time for the split/share apply to new patient visits too?

Answer: No.

Question: How is a Comprehensive Error Rate Testing (CERT) auditor going to look at things like a patient coming in for an acute uncomplicated condition such as a rash, but the provider spent 50 minutes on the visit?

Answer: The CERT contractor functions independently from the Medicare Administrative Contractor (MAC).

Same Day/Time

If the physician reviews old records from another service the day prior to patient visit, can this be added to time for the appointment the next day?

Answer: Yes.

Question: Will the changes apply to emergency medicine and hospitalist services E/M coding?

Answer: Not at the time of this presentation. See the MLN 12071 Final Rule 2021 (PDF, 255 KB).

Question: If the condition is not mentioned anywhere in the note other than in the assessment and plan, and links a med refill or lab to the condition, and there is evidence of a face-to-face visit, would this condition be considered managed at this encounter?

Answer: We would need to look at the actual documentation

Question: Do you have to state in the office note which one you are going to charge by?

Answer: No, the nature of the note will define how it is being charged. If it is wished to state what type of note it is, then that is up to the provider.

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