Question: When using the E/M guidelines, is the problem an acute, uncomplicated illness or an acute illness with systemic symptoms? Answer: Codes for Visits in Assisted Living (and a Visit Complexity Update for 2026!) Acute, uncomplicated illness Acute illness with systemic symptoms From CPT®: A recent or new short-term problem with low risk of morbidity […]
Critical Care Services
Definition and Explanation of Critical Care Service Definition: Coding service for caring for a critically ill or injured patient Explanation: Critical care has high relative value units and payments so it’s important to know the coding rules. This article describes what can be included in the time of critical care what can’t be included, and […]
CMS’s 2024 Shared or Split Services Policy: Document and Report Them Correctly
In 2024, CPT® expanded its definition of split/shared services, CMS updated their requirements. Neither CMS nor CPT® made changes to this policy in 2025 or 2026. Medicare requires that both practitioners are enrolled in Medicare, and both have E/M in their scope of practice. CPT® expanded its definition of split/shared services in 2024. The service […]
Billing for Pap Smear
Billing for pap smears in a physician practice can be confusing for clinicians and coders alike. Pap smears can be screening services or diagnostic services There is a HCPCS code for obtaining a screening pap smear, Q0091 Performing a pelvic exam is either part of a preventive medicine service or problem oriented visit CPT® add-on […]
G0101 Pelvic and Breast Exam
Medicare has HCPCS codes for screening services for women Both G0101 (screening breast and pelvic exam) and Q0091 (obtaining a screening pap smear) may be billed every two years for a low-risk patient and every year for high-risk patients These are not comprehensive preventive medicine services They may be billed on the day of a […]
Risk: Roads not Taken
How is risk assessed when selecting a level of E/M service? We know that the risk of additional diagnostic testing/procedures and management is one of the three elements that determines the level of service, when MDM is used to select a level of E/M. But, how about the risk of the condition itself? This short […]
Coding for Prolonged Services: CPT® and HCPCS Codes
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 […]
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
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 […]
Home and Nursing Facility Category of Code Rules | Webinar
Recorded March 21st, 2024
This webinar will explain the rules for using Evaluation and Management (E/M) services (E/M) in home and residence locations and nursing and skilled nursing facilities. This includes CMS regulations for nursing facility services. It will discuss reporting multiple E/M services when one of the visits is in a nursing facility, and more.
Coding Multiple Procedures | Examples with Modifiers
Biopsies and lesion destruction codes are often performed at the same patient visit. This leads to questions about bundling and modifiers. There are two steps to billing these correctly and avoiding denials: Check the total RVU values Check the NCCI edits. There is a step-by-step procedure for coding multiple procedures at the end of this […]
CPT® Codes (99421-99423) – and Payment for – Online Digital Evaluation and Management (E/M) Services
Or, as I call them: message, manage, message. There are CPT codes for online digital E/M services. CPT developed a set of CPT® codes for use by physicians, physician assistants and advanced practice nurse practitioners performing brief, online E/M services via a secure platform There are also CPT® codes for use by clinicians who do […]
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…
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