G. John Verhovshek, MA, CPC

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Employing non-physician practitioners (physician assistants, nurse practitioners, clinical nurse specialists, etc.) is an effective way to increase productivity in a physician office. However, under Medicare rules, covered services provided by non-physician practitioners (NPPs) are reimbursed at a reduced rate (85 percent of the fee schedule amount).

The “incident-to” billing rules provide an exception, allowing 100 percent reimbursement for non-physician services that meet the requirements detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60 (Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service).

There are six basic requirements to meet the incident-to guidelines for Medicare payment:

The Basics of Incident-To billing

Services meeting all of the above requirements may be billed under the supervising physician’s NPI, as if the physician personally performed the service. Documentation should detail who performed the service, and that a supervising physician was in the office suite (although not necessarily the same room), at the time of the service.

Remember: Incident to applies only to Medicare. Further, the requirements do not apply to services with their own benefit category. Diagnostic tests, for example, are subject to their own coverage requirements. “Depending on the particular tests,” the Benefit Policy Manual explains, “the supervision requirement for diagnostic tests or other services may be more or less stringent than supervision requirements for services and supplies furnished incident to physician’s or other practitioner’s services.”

Similarly, pneumococcal, influenza, and hepatitis B vaccines do not need to meet incident to requirements. MLN Matters Number: SE0441 elaborates:

Must a supervising physician be physically present when flu shots, EKGs, Laboratory tests, or X-rays are performed in an office setting in order to be billed as “incident to” services?

These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not “incident to” services and the “incident to” rules do not apply.

Additional rules apply for incident to physician’s services in clinic, and services incident to a physician’s service to homebound patients under general physician supervision. These can be found in the 

Medicare Benefit Policy Manual, Chapter 15, Section 60

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The Basics of Incident-To Billing

When reporting an evaluation and management (E&M) service on the same claim with another service or procedure, you must append either modifier 25 "

Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service,

Modifier Identifies Separate Nature of E&M Service

A minimal patient evaluation is necessary to determine that a prescribed treatment is appropriate to manage the patient's condition. For example, if a patient presents for a previously scheduled injection, the provider will briefly evaluate the patient to confirm that the injection remains the proper course of treatment. All billable medical procedures include this "inherent" E&M component.

Any E&M service reported must exceed the minimal evaluation and management typically included in other procedures or services billed on the same claim. A knowledgeable individual, looking at the available documentation, should be able to identify the important E&M components of history, exam, and medical decision-making (MDM), apart from any other procedures or services performed on the same day.

Identifying a significant, separately billable E&M service is easier if the provider documents the history, exam and MDM in the patient's chart, and records the procedure note on a different sheet attached to the chart, or in a different section within the EHR (although separate documentation is 

 Some E&M services may be reported using time - rather than history, exam, and MDM - if counseling or coordination of care comprise more than half of the total visit time. In such a case, you may use CPT "reference times," along with patient status and place of service, to determine an appropriate E&M service level. See the 

CPT Evaluation and Management Guidelines 

Modifiers 25 and 57 alert the payer, "This is not a bundled E&M service, but rather a separately billable service supported by medical necessity and clinical documentation." If you fail to append the proper modifier, the insurer will assume the billed E&M service is incidental to other services reported, and will not pay for it.

Typically, medical necessity and clinical documentation will support a separately billable E&M service when the patient presents with a new problem that requires evaluation and treatment. Or, the patient presents with an established problem that has worsened and requires further evaluation and a change in treatment plan. When an E&M service leads to an unplanned, same-day procedure, documentation must establish that the decision to perform procedure was made during the encounter.

Each CPT code reported must be linked to a diagnosis substantiated in the medical record. CMS Transmittal R954CP establishes that an E&M service "may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E&M services on the same date."

Global Period Determines Correct E&M Modifier

CMS and nearly all private payers classify non-E&M procedures as either "major" or "minor." This information is crucial to determine whether modifier 25 or modifier 57 is appropriate to append to the E&M service code reported.

Major procedures have a 90-day global period. All other procedures (e.g., those with a zero-day, 10-day, or other assigned global period) are minor procedures. You can find a global period look-up tool on the CMS website: 

cms.gov/apps/physician-fee-schedule/overview.aspx

If the provider furnishes a minor procedure and a separate E&M on the same date of service (at the same or a separate encounter), append modifier 25 to the E&M service code. Examples of minor procedures include many injections, minor integumentary repairs, and endoscopic procedures (e.g., diagnostic colonoscopy).

You normally will not report a separate, same-day E&M service if the provider sees a patient for a previously scheduled procedure or service. Per the 

 (Chapter 12, Section 40.1), "Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed."

Append modifier 57 to a separately identifiable E&M service that occurs on either the same day

, a major surgical procedure, and that results in the decision to perform the surgery, per Medicare's

CPT guidelines do not allow separate payment for a E&M service to clear a patient for surgery, after the decision for surgery has been made, stating, "Evaluation and management services subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)" are "included in addition to the operation per se."

Articles

When do you use modifier 25 or 57? Coding expert John Verhovshek explains the difference when coding an E&M service. 

How to Choose Between Modifiers 25 and 57 

Medicare payers, under the direction of CMS, reimburse for a variety of telehealth services, but only within carefully defined circumstances. Here are the basics you'll need to know to report telehealth services to Medicare, successfully.

Currently, CMS limits reimbursement for telehealth services to those represented by approximately 85 CPT and HCPCS Level II codes, including: psychiatric diagnostic procedures (90791-90792); select psychotherapy services (90832-90838); end-stage renal disease services (90951-90952, 90954-90956); outpatient evaluation & management (E/M) services (99201-99215); advanced care planning (99497-99498); annual depression screening (G0444), and more.

The list of Medicare-covered telehealth services is subject to change, each year. For a complete, current list of covered telehealth services, 

Covered telehealth services for 2017 also may be found in the Medicare Learning Network, "Rural Health Fact Sheet Series: Telehealth Services." The Telehealth Services Fact Sheet (accessed April 18, 2017) is the source of all quoted material in this article, unless otherwise noted. It can be found 

The Patient Must Be In an Approved "Originating Site"

For telehealth services billed to Medicare, the patient receiving the service must be in an approved originating site, which CMS defines as, "the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs."

 Per CMS, "beneficiaries are eligible for telehealth services, only if they are presented from an originating site located in a rural Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area."

A list of Health Professional Shortage Areas, by state and county, may be found on the Department of Health and Human Services Health Resources and Services Administration website (http://hpsafind.hrsa.gov). The U.S. Census maintains a list of Metropolitan Statistical Areas on its website (http://www.census.gov/population/metro/).

Entities that participated in a Federal telemedicine demonstration project prior to Jan. 1, 2001 qualify as originating sites, regardless of geographic location.

Second: An originating site must be of a kind authorized by law, which may include:

• Federally Qualified Health Centers (FQHC)

• Community Mental Health Centers (CMHC)

• Hospital-based or CAH-based Renal Dialysis Centers (including satellites): Independent Renal Dialysis Facilities are not eligible originating sites

Only Approved Providers May Report Telehealth Services

Practitioners who may provide and bill Medicare for telehealth services include:

• Registered dietitians or nutrition professionals

• Clinical psychologists (CP) and clinical social workers (CSW): however, CMS does not allow CPs and CSWs to bill Medicare for psychiatric diagnostic interview examinations with medical services or medical E/M services, to include 90792 (psychiatric diagnostic evaluation with medical service), 90833 (30-minute psychotherapy add-on code), 90836 (45-minute psychotherapy add-on code), and 90838 (60-minute psychotherapy add-on code).

Services billed must be within a practitioner's scope of practice under applicable state law.

CMS rules stipulate that as a condition of payment for telehealth services, providers "…must
use an interactive audio and video telecommunications system that permits real-time communication between [the provider], at the distant site, and the beneficiary, at the originating site. Asynchronous 'store and forward' technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii."

In other words, telehealth has to be delivered such that the patient and provider are in constant, two-way communication during the service.

When reporting an approved telehealth service, you must append modifier GT 

via interactive audio and video telecommunications systems

 to the appropriate service code(s). For example, to bill a level 4 established patient office visit provided via telehealth, report 99214-GT. By appending the modifier, the provider is certifying that the beneficiary was present at an eligible originating site when the telehealth service was furnished.

Special circumstance: When appending modifier GT with a covered end-stage renal disease (ESRD)-related service telehealth code (e.g., 90951 

ESRD related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with four or more face-to-face visits by a physician or other qualified health care professional per month

), you also are certifying that one visit per month was furnished "hands on" to examine the vascular access site, per the code descriptor requirement.

In those cases (limited to Alaska and Hawaii) when you may bill Medicare for non "face-to-face" telehealth services, report the appropriate code for the professional service with modifier GQ 

via an asynchronous telecommunications system

Payment for telehealth services is the same as for services furnished without the use of a telecommunications system.

Using telehealth services? Here are the basics on reporting this to Medicare, in order to get properly paid. 

Meeting Medicare Requirements to Report Telehealth Services

Transitional care management (TCM) describes the oversight and coordination of healthcare services for patients transitioning from an inpatient hospital setting. The CPT codebook provides codes and guidelines to report TCM, which allows providers to recoup payment for services they may already provide to their patients. Medicare covers TCM services, but the requirements occasionally differ from those in the CPT codebook.

The basic services comprising TCM may be found in the TCM code descriptors:

 Transitional Care Management Services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge

• Medical decision making of at least moderate complexity during the service period

• Face-to-face visit, within 14 calendar days of discharge

Transitional Care Management Services with the following required elements:

• Medical decision making of high complexity during the service period

• Face-to-face visit, within seven calendar days of discharge

Eligible transitions in care include discharges from an inpatient hospital, partial hospitalization, and hospital observation status. Transitions from a skilled nursing facility (SNF) or nursing facility to the patient's community setting (home, domiciliary, rest home, or assisted living community) also are included.

Both TCM codes require communication with the patient or caregiver within two 

 calendar days) of discharge. Specifically, CPT guidelines state, "The contact may be direct (face-to-face), telephonic, or by electronic means [e.g., e-mail]."

CPT defines business days as Monday through Friday, excepting holidays, "without respect to normal practice hours or date of notification of discharge." For example, if the patient is discharged on Tuesday, initial contact with the patient must be made before the end of business day, Thursday.

If the provider attempts to reach the patient or caregiver, but is unsuccessful within two business days, CPT allows that you still may be able to report the service. Medicare rules concur, "If you make two or more separate attempts in a timely manner 

 but are unsuccessful and if all other TCM criteria are met, you may report the service" [emphasis added]. CMS rules further specify, "…we expect attempts to communicate to continue until they are successful. You cannot bill TCM if the face-to-face visit is not furnished within the required timeframe."

 Department of Health and Human Services Centers for Medicare & Medicaid Services:

Medical Decision-Making as a Qualifying Factor

The TCM code descriptors stipulates medical decision-making (MDM) of either moderate (99495) or high (99496) complexity. As such, not all post-discharge patients will qualify for TCM services.

CMS defines MDM as "the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:

• The number of possible diagnoses and/or the number of management options that must be considered

• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed

• The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options"

To qualify for a given level of MDM, two of the three elements must be met or exceeded.

Number of Possible Diagnoses and/or Management Options 

Amount and/or Complexity of Data to Be Reviewed 

Risk of Significant Complications, Morbidity, and/or Mortality 

Further detail of the MDM component may be found in the 

Documentation Guidelines for Evaluation and Management Services 

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

TCM requires a face-to-face visit with the patient within 14 (99495) or seven (99496) 

 days of the patient's discharge from the inpatient setting. This visit is included as part of TCM and may not be reported separately.

Although not explicit in the code descriptors, medication reconciliation and management must occur no later than the date of the face-to-face visit, per both CPT and CMS. Medication reconciliation is the process of comparing a patient's medication orders to all of the medication that the patient has been taking, to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

Non Face-to-Face Services Comprise the Bulk of TCM

The requirements set forth in the TCM code descriptors represent only a portion of the work involved in providing these services. The bulk of the provider's (or staff's) efforts are primarily non face-to-face services to manage and coordinate the patient's care during the post-discharge period. Example services provided by a qualified healthcare professional (e.g., physician, or certified nurse-midwives, clinical nurse specialists, nurse practitioners, and physician assistants legally authorized and qualified to provide the services in the state in which they are furnished) include:

• Obtain and review discharge information (e.g., discharge summary or continuity of care documents)

• Review the need for, or follow up on, pending diagnostic tests and treatments

• Interact with other healthcare professionals who will assume care of the beneficiary's system-specific problems

• Provide education to the beneficiary, family, guardian, and/or caregiver

• Establish or re-establish referrals and arrange for needed community resources

Clinical staff, under the direction of the physician or other qualified provider, may furnish certain TCM services. These include:

• Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living

• Assess and support treatment regimen adherence and medication management

• Identify available community and health resources

• Assist the beneficiary and/or family in accessing needed care and services

A full list of services included in TCM can be found in the CPT codebook, and the previously referenced CMS Transitional Care Management publication.

TCM services are payable only once in the 30-day post-discharge period. The post-discharge period begins on the day of discharge and continues for the next 29 days.

Both CPT and CMS allow only a single provider to bill TCM, per discharge. Documentation of TCM services should include, at minimum:

• Date you made an interactive contact with the beneficiary and/or caregiver.

• Date you furnished the face-to-face visit.

• The complexity of medical MDM (moderate or high).

The individual billing for TCM services also may report hospital or observation discharge services. CMS differs from CPT in that it does 

 allow the face-to-face visit required for TCM to be furnished by the same provider on the same day as the discharge management service.

CMS stipulates that billing for TCM services should occur after the conclusion of the service (i.e., at 30 days post-discharge or thereafter). CPT

is more lenient, stating, "Only one individual may report these services and only once per patient 

CPT allows you to report TCM in addition to a procedure with a global period. Per CMS, a physician or NPP billing a procedure with a 10- or 90-day global period may not report TCM services, in addition.

Finally, both CPT and CMS prohibit billing TCM during the same 30-day period as other services, including care plan oversight, End-Stage Renal Disease services, complex chronic care coordination, and other services enumerated in the CPT codebook.

The above represents a summary of coding and documentation requirements to report TCM: Be sure to review the complete guidelines for your payer (whether they follow CPT\ or CMS guidelines) prior to reporting these services.

Everything you want to know about coding a transitional care management encounter, including what services are included. 

Transitional Care Management: Coding and Documentation in Brief

Moderate (or conscious) sedation is a drug-induced depression of consciousness, which may be provided during colonoscopy, cataract removal, or dental procedures, for example. The patient becomes relaxed and insensitive to pain, but remains awake and able to respond to verbal instruction.

In previous years, the American Medical Association (which produces the CPT codebook) and CMS disallowed separate reporting of moderate sedation in many circumstances. Nearly 450 CPT codes were valued to include moderate sedation when performed.

As of Jan. 1, 2017, CPT no longer defines moderate sedation as an inherent part of any procedure. Moderate sedation, when performed and properly documented, now may be reported separately. Per the 2017 Physician Fee Schedule Final Rule, "This coding change [provides] for payment for moderate sedation services only in cases where it is furnished."

Prior codes to describe moderate sedation (99143-99150) are deleted and replaced by six new codes that are assigned according to: who performs the moderate sedation (the same provider who performs the primary service, or another provider); patient age (5 years or younger, or older than 5 years); and, intraservice time of the moderate sedation.

Tip: CPT defines intraservice time as beginning with the administration of the sedation agent,and ending when the procedure is completed, the patient is stable for recovery status, and the provider performing the sedation ends personal continuous face-to-face time with the patient. Additional qualifications may be found in the Moderate Sedation portion of the CPT manual.

Same provider performs both the primary procedure and the moderate sedation:

 "Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age"

 "…initial 15 minutes of intraservice time, patient age 5 years or older"

 "Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (list separately in addition to code for primary service)"

If the same provider performs both the primary procedure and the moderate sedation that provider should bill for the moderate sedation; however, there must be a trained observer to assist. "CPT® Changes 2017: An Insider's View" provides a clinical example:

"A patient undergoes a procedure that requires moderate sedation. The treating physician will perform both the supported procedure and the moderate sedation service. The physician will supervise and direct an independent, trained observer who will assist in monitoring the patient's level of consciousness and physiologic status throughout the procedure."

In this case, suppose the patient is older than 5 years, and the intraservice time for the moderate sedation is 33 minutes. Proper reporting for the moderate sedation is 99152 (minutes 1-15) and 99153 (minutes 16-30). Per CPT guidelines, the minimum time requirement to report moderate sedation is 10 minutes, and at least seven minutes must pass to report an additional unit; therefore, minutes 31-33 are not reported.

If the circumstances were the same, but the patient is younger than 5 years, proper reporting is 99151 (first 15 minutes), 99153 (minutes 16-30).

Different provider performs primary procedure and moderate sedation:

 "Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age"

 "… initial 15 minutes of intraservice time, patient age 5 years or older"

 "Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)"

In these cases, the provider performing the moderate sedation - not the provider performing the primary procedure - bills the moderate sedation. No independent observer is necessary to monitor the patient. In other respects, reporting is the same as when using 99151-99153.

For example, a 4-year-old patient undergoes a procedure necessitating moderate sedation. Separate providers perform the primary procedure and moderate sedation. The intraservice time is 39 minutes. Proper reporting is 99155 (first 15 minutes of intraservice time for a patient 5 years old or younger) and 99157 x 2. The first unit of 99157 reports minutes 16-30. The second unit of 99157 reports minutes 31-39.

Tip: The CPT manual includes a chart to help you determine the proper number of units of moderate sedation to report, based on intraservice time.

Medicare Designates G Code for Moderate Sedation with Certain GI Endoscopy Services

CMS determined that the moderate sedation work for certain esophageal dilation, biliary endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP) procedures differs from that of other endoscopy procedures. For this reason, CMS augments the new moderate sedation CPT codes with a gastro-intestinal (GI) endoscopy-specific moderate sedation code, G0500 (

Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older

). You should report G0500 instead of CPT 99151-99152 when reporting moderate sedation to Medicare patients in addition to designated GI endoscopy services. For additional details and a full list of designated GI endoscopy services, see Table 26 of the 2017 Medicare Physician Fee Schedule Final Rule.

When reporting G0500 to Medicare, additional time beyond the initial 15 minutes of intraservice time may be reported using 99153 

Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)

Revised codes and coding guidelines for 2017 completely change reporting for moderate sedation services. Here's what you have to know.