Question: Can we bill Advanced Primary Care Management every month for a patient we sign up, even if we don’t provide any services during that month? Answer: In my opinion, no. The CMS website doesn’t address this directly in the article here. Here are comments from the 2025 Final Rule: “After consideration of public comments, we are […]
Monthly Coding Q&A
Our newsletter subscribers and our members have a coding question and answer delivered to their inbox monthly. Some topics are perennial and timeless, asked by new clinicians and team members all the time. Some answer questions about new rules and services. Do you want to receive our monthly Q&A? Sign up here.
Non-Physician Practitioners in Nursing Facilities
Question: Can a Non-Physician Practitioner (NPP) see patients in a nursing facility without a physician signing each encounter? How do we bill this? Can we do wellness visits in a nursing facility? Answer: Yes, NPPs may care for patients in a nursing home. These can either be billed directly by the NPP, under their own […]
Leveling a Visit for an Acute, Uncomplicated Presenting Problem
Question: What’s the accurate level of service for a patient who presents with a sore throat, has a positive strep test, and is put on antibiotics? Answer: The September 2025 CPT® Assistant posed this question and said the level of service was 99213. Let’s look at this in grid form to see why. You need […]
Does 99459 Require a Chaperone?
Question: The E/M session of the CPT® symposium this year was in question-and-answer format. One of the questions was, “Is a chaperone required to use add-on code 99459?” Answer: Their answer: no. Some consultants stated that in order to use code 99459 with an office visit, consult, or certain preventive medicine services, a chaperone was […]
Crediting Independent Interpretation
Question: Can a practitioner get credit for both ordering and interpretation of a test if documented? Can you address the change from 2023 related to this? Watch this brief video or read on for the answer. Answer: In March of 2023, CPT® issued an “Errata and Technical Corrections” which added one line to the section […]
Teaching Physician Rules – Moonlighting
Question: Resident is moonlighting in an urgent care setting. The resident is licensed but not enrolled with insurance companies. Can we follow the Teaching Physician rules for this resident and bill for services jointly performed between an attending and the resident? Answer: For Medicare, no, not based on my reading of the applicable statutes. “Moonlighting” specifically refers to […]
Visits in the Maternity Package
Question: How many visits are included in the payment for the maternity care package? Answer: The global maternity package includes approximately 13 routine antepartum visits for an uncomplicated pregnancy: monthly visits up to 28 weeks, biweekly visits to 36 weeks, and weekly visits until delivery. Fewer than four prenatal visits do not qualify for global reimbursement and […]
Advance Care Planning Q&A
Does your practice provide Advance Care Planning (ACP) services? If so, read on and watch the video below. Q: Can it be billed as a group service? A: No. It is a service to an individual beneficiary and/or their family member(s) or surrogate. Q: Does it follow the mid-point rule? Should I start to bill 99497 at 16 […]
Transferring a Sick Baby to Another Hospital
Question: Our pediatric group practices in a community hospital, without an NICU. My pediatrician was called to attend a delivery of a newborn who was born premature and in respiratory distress. The baby needed to be stabilized and transferred to a level III neonatal intensive-care unit. The pediatrician spent 90 minutes from the time the […]
Codes for Visits in Assisted Living (and a Visit Complexity Update for 2026!)
Question: In 2026, how will we indicate practitioners are providing longitudinal or complex care who are in assisted living or receiving services in their home? Answer: In 2023, the codes for services performed in a patient’s home or in an assisted living facility were combined to one code set. Codes (99341—99345 for new patients) and (99347—99350 […]
Acute, Uncomplicated vs. Acute with Systemic Symptoms
Question: When using the E/M guidelines, is the problem an acute, uncomplicated illness or an acute illness with systemic symptoms? Answer: Let’s start with the CPT definitions, from the CPT® Professional edition. Acute, uncomplicated illness Acute illness with systemic symptoms From CPT®: A recent or new short-term problem with low risk of morbidity for which […]
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.
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 […]
Medicare Advantage Plan Network Issues
Question: My sister is thinking of enrolling in a Medicare Advantage plan. In our practice, we have issues with pre-authorizations and denials. I’ve warned her about network issues. Is there anything else I should tell her? Answer: I’m so glad you asked. I’ve had this conversation with my own family and friends. Medigap plans If […]
Compliance Issues in ICD-10 Coding for Risk Based Contracts and HCCs
Everyone loves to read the general guidelines at the front of the ICD-10 book, right? No? Well, here’s an important excerpt. “Code all documented conditions, which coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions, which no longer exist).” Most of the articles I’ve written […]
Can We Bill a New Patient Visit for Preventive and E/M Services on the Same Day?
See our on-demand webinar, Preventive medicine and Medicare wellness visits with an E/M. Question: Our physician saw a patient and did a preventive medicine service and addressed an acute, significant problem. The patient was new to us. Should we bill both as new patient visits? Answer: The last time I saw this addressed by CPT® […]
Diagnosis Coding for Biopsy Sent for Pathology
Question: What diagnosis code should you use when sending a skin biopsy to pathology? a) D48.5 Neoplasm of uncertain behavior of skin, or b) D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin