Common rules: Prolonged services codes are add-on codes to the highest level E/M services in certain categories. In order to use prolonged care, the primary code must be selected based on time. This is in the CPT® and HCPCS definition of prolonged services. Prolonged services codes may only be added to the highest-level code in […]
Nursing Facility Visits
Definition Nursing facility visits are Evaluation and Management services provided in a skilled nursing facility (SNF) or a long-term care facility (LTCF) (sometimes abbreviated as NF for nursing facility. Explanation Only a physician may perform an initial nursing facility service in a SNF. This includes admissions and re-admissions. In an LTCF, a non-physician practitioner (NPP) […]
Preventive Medicine Services – Medicare
Medicare has very specific requirements for preventive services. What can you bill, what must you document? This article covers all the bases including tips for billing the Welcome to Medicare and Annual and Subsequent Wellness Visits. More tips for preventive medicine and split visits can be found here. See also Q&A from the Preventive Medicine […]
Shared Services: CPT® and CMS Rules | Webinar
Recorded May 16th, 2024
1 CEU expires 5/30/26
Shared services are E/M services jointly performed by a physician and non-physician practitioner in a facility setting. The service is reported under the National Provider Identifier (NPI) of the practitioner who performs the substantive portion of the service. The substantive portion of the service can be determined by time or medical decision making (MDM).
What is the Risk of a Referral?
Question: What level of risk is assigned when a practitioner refers a patient to a physician in another specialty? Does the complexity of the problem (eg, melanoma) make a difference? Answer: Watch this brief video for the answer. You can also download the slides here.
Preventive Medicine, Wellness Visits and Problem-Oriented Visits | Webinar
Recorded April 18th, 2024
1 CEU expires 5/30/26
Two for the price of one? Or, double-billing? There are varying opinions about when the documentation supports adding a problem-oriented visit to a CPT® preventive service or a Medicare wellness visit. This webinar provides a framework for determining if documentation shows the additional work that was done.
OIG Report on Telehealth During the PHE
What? An OIG report without doom and gloom? Fire and brimstone? Slides In February, 2024 the OIG released an audit report of telehealth E/M services performed between March 2020 and November 2020. During this nine-month period practitioners submitted claims for 19 million E/M services. Before I talk about the report though, let me congratulate everyone […]
E/M Frequency Data for Hospitalists
Hospitalists became a recognized specialty by CMS starting in 2017, and we now have frequency E/M data for the specialty. There are probably still physicians who have not switched their specialty designation. Physicians self-elect their specialty designation with Medicare and other payers. Many hospitalists are family medicine or internal medicine physicians by training, working as […]
E/M Frequency Data for Family Medicine and Internal Medicine
CMS releases E/M frequency data annually. A physician self-elects their specialty designation when enrolling with Medicare. The panel for family medicine physicians includes children, but the data below is Medicare data, for disabled patients of any age and people 65 and older. I opted to show internal medicine and family medicine together, because both are […]
Multiple E/M Services in the Same Calendar Day
The AMA added a new subsection in the 2024 E/M section addressing how to report E/M services when there are multiple encounters in the same day. (Pages 6 and 7) According to CPT® Changes 2024 An Insider’s View, the reason for this was to provide clarification for when multiple E/M services were performed on the […]
Teaching Physician – Primary Care Exception
CMS updated the teaching physician rules in 2019, and this article reflects the change. On April 26, 2019 CMS released Transmittal 4283. The transmittal primarily addresses E/M services, but also amends the section of the manual related to the primary care exception. The changes to the primary care section were mostly wording updates. Those rules […]
2026 RVU Table
Looking for 2026 total RVUs? Or work RVUs? This year, and in coming years, there are two conversion rates, so we haven’t done the fee calculation. For practitioners who are Qualified Professionals in a Medicare Shared Savings plan, the conversion factor is $33.57. For non-QP Professionals, the conversion factor is $33.40. If you want to […]
How Physician Services are Paid – Overview
Have a new staff member or physician who needs a primer on “how physician services are paid?” This short video is a must see! Learn how all the piece come together, from CPT® and HCPCS, to diagnosis coding and Medicare rules. All in about 15 minutes…
Two Visits for the Price of One? | Multiple Medical Visits on the Same Day
Patients often schedule two medical appointments on the same day with physicians of different specialties. It’s convenient for them. It saves travel time. It may mean the patient or a family member only needs to take one day off work. Can a multi-specialty practice be paid for two visits, when the physicians/non-physician practitioners (NPPs) practice […]
HCC Coding: V24 to V28
The transition from V24 to V28 of the HCC model is almost in the rear view mirror. For most groups with risk contracts, this really is old news. We’ve left the video for another year for anyone who needs to catch up on the overview of the change. CMS pays Medicare Advantage (MA) plans using […]
Age and Wellness Visits | Eligibility for Welcome to Medicare
Who can perform the AWV Knowing which Medicare wellness visit to bill Eligibility requirements for the Welcome to Medicare visit AWV and chronic care management A few years ago, I gave an AWV presentation at a family medicine conference and afterwards a physician said to me, “What you just told me will pay for the […]
Facility versus Non-Facility in the Physician Fee Schedule
Understanding facility versus non-facility in the physician fee schedule explains the total RVU and payment differences that practices receive when performing the same service in different settings. The Medicare Physician Fee Schedule has values for some CPT® codes that include both a facility and a non-facility fee. Some services may be performed in either an […]
What is a Coverage Policy?
National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) are Medicare coverage policies that describe medical necessity for certain services. Individual Medicare Administrative Contractors develop LCDs. These policies describe the service and covered indications. They can also include what professionals may perform the service. Some describe conservative treatments that must be tried before the procedure […]
HCPCS Code G0136 Update
CMS is changing the definition of HCPCS code G0136. They are keeping the code, and the valuation of the code. The code is staying on the telehealth list. But there is a completely new definition. Between now and 12/31/2025, G0136 is for an assessment of a patient in the areas of social determinants of health […]
How Do We Code for “Meet and Greet Visits?
Question: What code can I use when a patient presents to establish care, and doesn’t have any symptoms or problems? Answer: First, code or no code, isn’t this a great position for the patient to be in? Establishing care without a care in the world? (Medically at least.)
E/M Services: High Volume, High Risk | Webinar
Recorded October 19, 2023
According to CMS, E/M services comprise 40% of allowed charges in the physician fee schedule, 20% office visits and 20% other E/M services. Medicare’s expense is medical practice revenue, with the income from some primary care practices comprising 70% or more of total charges. To protect the organization, compliance professionals can focus on four components of E/M.
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