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 […]
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.
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 […]
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 […]
2025 RVU table with national fee amounts
Looking for 2025 work RVUs? Wondering how much a new code pays? Look no farther. You can download the 2025 CMS national RVU table below. It does not include payment variations after the geographic practice cost indices have been applied. We’ve hidden some columns (which you can unhide) so that you see the code, short […]
HCC Coding: V24 versus V28
Medical practices are assessing the impact of the change in the HCC model from V24 to V28, a phased in change that begins in 2024. CMS pays Medicare Advantage (MA) plans using Hierarchical Condition Categories (HCCs), and many private payers and ACOs use the HCC model for risk adjustment. Briefly, Medicare pays MA plans more […]
Facility versus Non-Facility in the Physician Fee Schedule
Understanding facility versus non-facility in the physician fee schedule explains the 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. When CMS develops the fee schedule, each code has […]
HCPCS Code G0136 for Assessment Social Determinants of Health (SDoH)
HCPCS code G0136 for an assessment of patients a practitioner suspects may have difficulty with accessing treatment and following a treatment plan due to Social Determinants of Health (SDoH0 CMS established a standalone code G0136 (a HCPCS code) for the assessment of SDoH. They define SDoH into broad groups: “economic stability, education access and quality, […]
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 […]
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.) There isn’t a CPT code for “meet […]
Is ChatGPT Coming to Coding?
Question: What’s all this I hear about ChatGPT? Is it coming to coding? Answer: All right, I wrote that question myself. I’ve been thinking about this topic. Alicia Gallegos wrote an article for CodingIntel about the topic. But, I wanted to see for myself how it could interpret coding rules, so I asked ChatGPT questions […]
Coding Matters™
Health care coding news matters to coders, billers administrators and practitioners in medical practices. Often, there’s new beyond new codes or new policies and keeping up-to-date with that news can inform decisions that practices make. CodingIntel’s Coding Matters® page will help you be in the know about government regulation, compliance actions, third-party policies and the […]
CMS Finalizing Principal Illness Navigation (PIN) Services
This is information from the 2024 Physician Fee Schedule Final Rule https://public-inspection.federalregister.gov/2023-24184.pdf CMS developed four HCPCS codes for Principal Illness Navigation. This service is intended to help patients with serious conditions navigate their health care treatment. PIN services are incident-to services so may only be performed in a non-facility setting Informed consent is required-the patient must […]
Medicare Coverage for Marriage and Family Therapists and Mental Health Counselors
In the Consolidated Appropriations Act, 2023 Congress mandated that Medicare provide coverage and payment for the services of health professionals who are Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs). The effective date of coverage is January 1, 2024. And of course, these professionals must enroll in Medicare in order to provide the […]
What are Social Determinants of Health?
Question: Can you settle this question for our coding team? Are smoking and drinking considered Social Determinants of Health? Answer: No. According to the CDC: “Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set […]
Coding Clinic Update, 2Q, 2023
Dr. Kennedy has generously allowed me to share his summary. He emphasizes that he is paraphrasing the recent advice in the spirit of “fair use” and we are responsible (and must) read the official advice directly from the Coding Clinic in light of previous Coding Clinic advice and in the context of the official ICD-10-CM conventions and guidelines. […]
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 […]
As Time Goes By
One of the complexities for medical practices is using time in CPT® coding. CPT® has long had a unit of time rule that a unit of time is met when the midpoint has passed. That is, you’ve reached an hour after 31 minutes. There are many CPT® codes that follow this mid-point time rule including […]
Clinical Staff Time
Question: I believe that I know the answer to this question but am hoping you know the source, as I can’t find it—if a nurse helps with ROS, medication reconciliation, etc., would their time (if documented) be able to be included in the time for the visit? Answer: No. The answer to this question is […]
Payment Denials for Unspecified Codes
From the day coders got their first glimpse at ICD-10 codes, the question went out in the land: “Will payers deny unspecified codes?” Recently, a client told me that she was seeing an increase in denials for unspecified codes from payers and I wanted to gather more information about that. Thank you to the 140 […]
Does a Practitioner Need to Document Time for a Telehealth Visit?
Question: Does a practitioner need to document time for a telehealth visit? What if it is audio only? Answer: First: For a telehealth visit, always document if it is with video or audio only. Documenting “telehealth visit” or “telemedicine visit” doesn’t differentiate this. Second: If you are using office visit codes (99202—99215), you can select […]