Evaluation and Management (E/M): General Guidelines Webcast - Questions and Answers

The following questions were received during our September 19, 2019, webcast.

QUESTION 1: For counseling and coordination of care, what specific documentation is required regarding "context of the discussion?" Can the physician just state a blanket statement, such as "the risks and benefits were discussed with the patient and they understand them," or do they need to list all risks, benefits, etc., that they discussed with the patient and notate that they understand them?

Answer 1: There should be enough documentation that is specific to the patient/provider counseling session to support the counseling elements that were covered and the amount of time that was involved.

Question 2: Thank you for the response regarding content of counseling/coordination documentation. I looked at the patient example provided and it stated provider discusses test result, diagnosis and type of cancer, treatment options, side effects, lifestyle changes. Can they document those generic phrases? Or should they outline the treatment options, life style changes, etc. specific to that patient?

Answer 2: The documentation should be specific to the patient encounter. The specificity allows the provider and others reading the record to tell what precisely the provider and patient discussed at the time of that visit.

Question 3: The physician electronically signs off on their dictation but a letter is generated for our E/M service to be sent to the referring provider — can the ancillary staff sign the letter with their initials?

Answer 3: According to the MLN Complying with Medicare Signature Requirements Fact Sheet, the guidelines for using an electronic signature are:

  • Systems and software products must include protections against modification, and you should apply administrative safeguards that correspond to standards and laws
  • The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the attested information. (There are additional guidelines for electronic orders.)

Additionally, in regards to signing with initials, per the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 — Signature Requirements, a valid signature should be legible and include the provider’s name and credentials. Per the guidelines, the provider’s initials are acceptable when they are by the typed name of the provider on the same document or the documentation is accompanied by a signature log or signature attestation statement.

Resources:

  • MLN Fact Sheet (PDF, 536 KB) — Complying with Medicare Signature Requirements
  • IOM Pub. 100-08 — Medicare Program Integrity Manual, Chapter 3 (PDF, 598 KB), Section 3.3.2.4 — Signature Requirements

Question 4: MLN article MM11171 indicates significant changes to the teaching physician guidelines in that the resident, nurse, or other staff can now document the teaching physician's presence and participation. In light of this, if a resident performs an E/M and documents the teaching physician's presence and participation, what if anything does the teaching physician have to personally document? Also, does the teaching physician have to sign off on the resident's documentation?

Answer 4: E/M services billed by teaching physicians require that they personally document at least the following:

  • That they performed the service or were physically present during the key or critical portions of the service when performed by the resident
  • The participation of the teaching physician in the management of the patient

When assigning codes to services billed by teaching physicians, reviewers will combine the documentation of both the resident and the teaching physician.

Addendum: MM11171 — Documentation of Evaluation and Management Services of Teaching Physicians states "For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:

  • That the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
  • The participation of the teaching physician in the management of the patient."

The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.

However, for documentation by students, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

The second part of this question is about provider signature, "Also, does the teaching physician have to sign off on the resident's documentation?"

The answer is that Medicare "requires the signature as a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation." So yes, the provider must sign to show approval of the resident’s documentation and acceptance of the contents because the provider is billing as the professional who performed the service.

Resource:

  • MM11171 (PDF, 190 KB) — Documentation of Evaluation and Management Services of Teaching Physicians

Question 5: I believe the guidance you provided are the former guidelines from prior to July 29. MM11171 had an implementation date of July 29 and states the teaching physician no longer has to personally document that info and instead that notes by residents and nurses are sufficient to substantiate the teaching physician's presence and participation.

Answer 5: It is correct that the MM11171 states, "The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses."

Resource:

  • MM11171 (PDF, 190 KB) — Documentation of Evaluation and Management Services of Teaching Physicians

Question 6: In an E/M, if the physician is unable to examine a certain organ system or body area and documents the reason why, can that organ system or body area still be counted in the Exam component of the E/M?

Answer 6: Yes. If a provider addresses the organ system/body area and documents a reason that prohibits the exam, credit may be given for addressing the system.

Question 7: Hi. Can you please provide more specificity on how Railroad Medicare assesses "medical necessity" for an E/M? Is the "Presenting Problem" column of the Table of Risk used as a guide? It is often difficult for non-clinical coding/auditing staff to attempt to assess medical necessity in the absence of any method of quantification or recommendations from Medicare for assessing medical necessity among E/M levels.

Answer 7: Railroad Medicare follows the general instructions of CMS medical necessity guidelines that are in the CMS MLN Evaluation and Management Services Guide (PDF, 3.9 MB). "Services must meet specific medical necessity requirements in the statute, regulations, and manuals and specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations (if any exist for the service reported on the claim). For every service billed, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary."

The Evaluation and Management Services Guide contains information on the presenting problem and also types of medical decision making both of which are influenced by the medical necessity of the service. The guide has a Table of Risk (see page 84) which provides examples of presenting problems and the type of management options that might correspond to the problem’s level of risk and assist you in supporting both medical necessity and in choosing the code level for the service.

Resource:

Question 8: If the E/M documentation doesn't identify a chief complaint (CC) in the History portion of the note but the Assessment indicates the condition for which the patient seen, would Railroad Medicare deem that E/M as non-payable due to lack of a Chief Complaint?

Answer 8: The Medicare guidelines state "The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words." Also, "[t]he medical record should clearly reflect the chief complaint." There is no required format for a provider’s documentation. However, the chief complaint should be clearly identified somewhere in the provider’s documentation.

Resource:

Question 9: Hi. Since CPT indicates the presenting problems for both 99214 and 99215 are usually moderate to high, what is the difference between the two levels specifically in regards to medical necessity? For example, if a Comprehensive History and Comprehensive Exam are documented and the Decision Making is Moderate, and only 2 of 3 key components are necessary for this category of codes, what factor(s) would Railroad Medicare use to make the determination of whether the appropriate code for that service was CPT code 99214 or 99215? Thank you!

Answer 9: The American Medical Association Current Procedural Terminology CPT 2018® book does state the CPT codes 99214 and 99215 codes usually have a presenting problem of moderate to high severity. The difference for the use of the codes is in the Medical Decision making element. Moderate medical decision making is a key element for CPT code 99214. So if the documentation follows the example in your query, Comprehensive History, Comprehensive Exam and Medical Decision Making of moderate complexity would be coded as CPT code 99214.

Medicare policy is that Medicare will cover services at the medically necessary level. The CMS MLN Evaluation and Management Services Guide (PDF, 3.9 MB), instructions on selecting the code that best represents the service furnished states "billing Medicare for an E/M service requires the selection of a Current Procedural Terminology (CPT) code that best represents:

  • Patient type
  • Setting of service, and
  • Level of E/M service performed"

Since the provider in the example performed a service that most closely matched the 99214 code that is the level of service which should be submitted.

Question 10: If a provider leaves a group and joins a new group with new tax ID # but has several patients to follow them, are these patients still considered established patients or would they be considered new patients?

Answer 10: They would be considered established patients if they have received professional services from the provider within the previous three years. New patients are patients who have not received any professional services, i.e., E/M services or other face-to-face services (e.g., surgical procedures) from the physician or physician group practice (same physician specialty) within the previous three years.

Question 11: Are any abbreviations for example for diagnoses or procedures performed allowed in the clinical documentation examples: HTN, PNA, HLD, BLE, AVR, APR, etc.?

Answer 11: Abbreviations that are widely accepted and used are allowed in documentation. If there are any used in your specialty or office that may be less widely known, we encourage you to send a key with your documentation to explain your abbreviations.

Question 12: How many elements in an individual system constitute the difference between a limited exam and extended exam, when choosing level of exam?

Answer 12: According to the CMS MLN Evaluation and Management Services Guide (PDF, 3.9 MB), an examination may involve several organ systems or a single organ system. The type and extent of the examination performed is based on clinical judgment, the patient’s history, and nature of the presenting problem(s). A single organ system examination involves a more extensive examination of a specific organ system. The guide has a table on page 12 that details the required number of elements for single organ system examination. There are four levels of exam; Problem focused, Expanded Problem Focused; Detailed and Comprehensive. The guide also has specific single organ system examinations beginning on page 55 of the guide. 

Type of Examination
Description
Problem Focused
Include performance and documentation of one to five elements identified by a bullet, whether in a box with a shaded or unshaded border.
Expanded Problem Focused
Include performance and documentation of at least six elements identified by a bullet, whether in a box with a shaded or unshaded border.
Detailed
Examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet, whether in a box with a shaded or unshaded border.
Eye and psychiatric examinations include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or unshaded border.
Comprehensive
Include performance of all elements identified by a bullet, whether in a shaded or unshaded box.
Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected.

Question 13: If a patient is seen by provider in hospital at 11:50 p.m. and being evaluated but provider is not done with note until 12:30 a.m. Which date is correct to use for date of service?

Answer 13: It would be appropriate to use the date upon which the documentation is completed as the date of service. The medical record should document the date of service billed.

Question 14: Regarding the chief complaint, can it be listed elsewhere in document, such as under HPI stating reason the patient is here?

Answer 14: Yes, the chief complaint can be stated in the HPI portion of the documents.

Question 15: What is considered a short time for transcription regarding provider signatures?

Answer 15: According to the Medicare Program Integrity Manual, IOM PUB. 100-08, Chapter 3, Section 3.3.2.4 Signature Requirements, "Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process." The signature authentication process includes signature logs and/or signature attestations.

Resource:

  • IOM Pub. 100-08 — Medicare Program Integrity Manual, Chapter 3 (PDF, 598 KB), Section 3.3.2.4 — Signature Requirements

Question 16: Billing critical care-NP sees patient and documents CC time for 40 minutes, then MD see patient and does attestation and states his CC time of 50 minutes. This visit is separate from NP earlier that same DOS. Are we supposed to bill CPT code 99291 for MD and CPT code 99291 for NP? Or bill CPT code 99291 for MD and CPT code 99292 for NP? Both providers work for same practice.

Answer 16: The Medicare Claims Processing Manual, IOM Pub. 100-04, Chapter 12, Section 30.6.12, Subsection I. Critical Care Services provides by Physicians in Group Practice has specific guidance on this issue:

  • The initial critical care time (billed as CPT code 99291) must be met by a single physician or qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date. A history or physical examination performed by one group partner for another group partner in order for the second group partner to make a medical decision would not represent critical care services.
  • Subsequent critical care visits performed on the same calendar date are reported using CPT code 99292. The service may represent aggregate time met by a single physician or physicians in the same group practice with the same medical specialty in order to meet the duration of minutes required for CPT code 99292. The aggregated critical care visits must be medically necessary and each aggregated visit must meet the definition of critical care in order to combine the times.
  • Physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date. Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill and be paid as though each were the single physician.
  • Physicians in the same group practice, with different specialties, who provide critical care to a critically ill or critically injured patient may not always each report the initial critical care code (CPT code 99291) on the same date. When these physicians are providing care that is unique to his/her individual medical specialty, and are managing at least one of the patient’s critical illness(es) or critical injury(ies); then the initial critical care service may be payable to each.
  • However, if a physician (or qualified NPP) within a group provides "staff coverage" or "follow-up" for each other after another group physician provided the first hour of critical care services on that same calendar date but has left the case; the second group physician (or qualified NPP) should report the CPT critical care add-on code 99292, or another appropriate E/M code.

Resource:

  • IOM Pub 100-04, Chapter 12 (PDF, 1.4 MB), Section 30.6.12

Question 17: Will you be providing more detailed webinars concerning Exam and MDM? There are many gaps particularly in the 95 guideline we would like closed.

Answer 17: Railroad Medicare does plan to present more detailed webinars on E/M issues in the 2019-2020 year. We encourage you to visit our website www.PalmettoGBA.com/RR.

You can see previous and future planned events by accessing the Education/Events dropdown list on the green bar at the top of our homepage.

We also encourage you to sign up for our Palmetto GBA Listserv. You can choose Listserv on the top black bar at the top of our homepage. That will allow you to access a registration page to receive email updates, including information on upcoming presentations.

Question 18: I am curious- no one seems to be touching bases on how EMR (electronic medical records) takes away from the personability from E/M documentation. Are there any proposals about streamlining E/M documentation via a computer?

Answer 18: CMS has an Electronic Health Records page on the website. We encourage you to visit this page as Medicare guidelines are frequently updated throughout the year.

Question 19: Are there specific articles related to CPT modifier 24 and 59?

Answer 19: Railroad Medicare has Modifier Lookup articles for CPT modifiers 24 and 59. You can access these articles from our Forms/Tools page. See also the CMS MLN article SE1418 Proper Use of Modifier 59.

Resources:

Question 20: The E/M guide book mentions single system examinations for different specialties like cardiology, ENT (Ear, Nose and Throat), Genitourinary, etc. Our specialty is Gastroenterology (GI). Are there any guidelines for the GI system?

Answer 20: There is not a specific single system checklist for the GI system in the CMS MLN Evaluation and Management Services Guide (PDF, 3.9 MB).

If Medicare has not published a system specific checklist for your specialty, we encourage you to use the General Multi-System Examination list that is in the publication.

Question 21: I have a question regarding the time component of an exam. If patient has a basic condition like low back pain and sciatica, however they are very detailed in history of back pain could we still support a 99203 level exam?

Answer 21: The American Medical Association Current Procedural Terminology CPT 2018® book does state code 99203 has the key elements of detailed history, detailed exam and medical decision making of low complexity, usually having a presenting problem of moderate severity. The definition of moderate severity in the CPT 2018® book states, “A problem where the risk of morbidity without treatment is moderate… or increased probability of prolonged functional impairment.”

According to the CMS MLN Evaluation and Management Services Guide (PDF, 3.9 MB), the Table of Risk (page 35) lists a moderate level presenting problem of “one or more chronic illnesses with mild exacerbation, progression, or side effects of treatment.” In your example a patient with a detailed history of low back pain and sciatica would appear to qualify as a chronic illness with exacerbation.

If the documentation follows the example in your query, with a detailed history, detailed exam and medical decision making of low complexity, the visit would be coded as a 99203. Examples of low complexity of medical decision making for this patient might be the direction to use over-the-counter drugs and an order for physical therapy.

Question 22: When will the change of combining 99213 and 99214 take effect?

Answer 22: CMS has not finalized plans for the E/M coding changes. We encourage you to stay informed by frequently visiting the CMS Patients over Paperwork homepage.

Question 23: For purposes of determining whether a patient is a new patient or established patient for an APP (Advanced Practice Provider) (NP or PA), are they considered to have specialties? For example, if an NP who specializes in neurology and an NP who specializes in Family Medicine see the patient a year apart, would the second visit is considered a new patient visit or an established patient visit?

Answer 23: Non-physician practitioners are assigned specialty codes. A nurse practitioner (NP) is assigned the code 50 while a physician assistant (PA) is assigned the code 97.

In your question two NPs, both with the specialty code 50, see the same patient. The second visit would be considered an established patient visit as both APPs are of the same NP specialty 50. In the Medicare enrollment process, NPPs do not presently have specialty designation codes that allow them to identify a certain type of practice. Because of this, when determining between new and established patient status, it does not make a difference in that the NPs are in separate departments of the same clinic. As they are of the same specialty (50), at that group practice, only the first NP visit could be considered a new patient visit.

Question 24: Are an ophthalmologist and optometrist within the same group considered same specialty? If a patient sees an optometrist and that provider refers the patient to an ophthalmologist in the same group, is the ophthalmologist visit coded new or established?

Answer 24: Ophthalmology is specialty 18 and Optometry is specialty 41 — so they would be considered separate specialties. The ophthalmology service would be new patient visit.

Question 25: For MBI numbers, sometimes there is a difference in spelling with spaces, etc. The HIC number would still pull up the patient showing the difference, why does the MBI number not pull up the patient as the HIC number did?

Answer 25. When checking eligibility with a Medicare Beneficiary Identifier (MBI) or a Health Insurance Claim Number (HICN), the patient’s name should be entered as it appears on their Medicare card. If you are experiencing an issue with the Railroad Medicare Interactive Voice Response unit or the Palmetto GBA eServices portal eligibility functions, please call our Provider Contact Center at 1—888—355—9165.

Question 26: What is the course number for this webcast?

Answer 26. The course number for this webcast is RRB2071825

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