Can I get paid to sign the home health certification form?

CMS pays a small fee for the planning, certification, supervision and re-certification of home health services.  Don’t do the work and forget to get paid. Click the link below to watch this brief video about getting paid to sign the home health certification form.

Can I get paid to sign the home health certification form

For more coding resources visit


Medicare will pay for non-face-to-face prolonged services starting January 1, 2017 Codes: 99358 and 99359

Does this sound familiar? Before a visit with a new patient, the physician or non-physician practitioner receives old records. A stack of old records. And, these EHR printouts aren’t always organized in any way and frequently include pages and pages of non-information. (Don’t tell CMS we can’t send these electronically, but instead print the EHR record, mail it and then scan it into the next EHR.) What does the physician or NPP do? Now, spends his or her own time reviewing the records.

Starting January 1, that is a paid service, if it takes 31 minutes or more.

Truly, if the clinician meets half of the threshold time for the prolonged service without face-to-face contact (31 minutes), Medicare will pay. And the best part of this announcement: CMS will pay using CPT codes not HCPCS codes and follow CPT coding rules.

99358 Prolonged evaluation and management service before and/or after direct patient care, first hour

+ 99359 each additional 30 minutes (List separately in addition to code for prolonged services)

CPT Rules:

  • This service may be provided on the same day or on a different day than the face-to-face service.
  • It is for extensive time in addition to seeing the patient, and must relate to a service for a patient where direct face-to-face patient care has occurred or will occur and be part of ongoing patient management.
  • Code 99358 is not an add-on code. That is it can be reported on the day when no other service is provided.
  • Code 99359 is an add-on code to code 99358.
  • The time during the day a non-face-to-face service does not need to be continuous.
  • CPT tells us not to report these services during the same month as complex chronic care management (99487, 99489) or during the service time of transitional care management (99495, 99496).
  • You cannot double count the time for these non-face-to-face prolonged services codes and time spent in certain other activities represented by specific CPT codes. However, the list of CPT codes are mostly those which have a status either non-covered or bundled by Medicare. (Care plan oversight: 99339, 99340, 99374—99380; anticoagulant management: 99363, 99364, medical team conferences: 99366—99368, online medical evaluations: 99444, or other non-face-to-face services that have more specific codes and no upper limit in the CPT codes.

The example given in the CPT book is for extensive record review. However, there could be other coordination services that meet the requirements.

Because Medicare is following CPT rules for these services then the CPT rules related to time is in effect. I always think this is a “through the looking glass rule.” However it is a well-established CPT principle. For a service defined with a time component, the clinician must meet over half of the time stated. In the introduction in your CPT book under the heading time it states “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed.” In the case of these non-face-to-face prolong surfaces that means that 99358 maybe reported when 31 minutes have been spent. In order to report the add-on code 99359, 76 minutes would need to be spent in the non-face-to-face prelaunch services work. There is no provision or splitting this work over to calendar dates. This time rule does not relate to the stated times for E/M services.

Neither CPT (nor Medicare in their final rule) limits the specialty of physician or NPP who can perform these services. Although CMS discusses it in the section related to improving payment accuracy for primary care, there is no prohibition for other specialties using these codes. These codes could be relevant for any physician or NPP who needs to review extensive records prior to a patient visit when the time reaches the 31 minute threshold.

And of course, document time in the medical record and briefly describe the work that was done.

January 24, 2017 I am giving a webinar “New revenue opportunities for primary care in 2017.” Check back: I’ll post an announcement about registering in late December.




End confusion about modifier -57 (and get paid for initial evaluations)

Recently I completed an audit for a general surgery practice. Included in the audit were two services for an initial hospital visit on the day of an emergency surgery. Both of these were reported with modifier -25 on the evaluation and management (E/M) service and both were denied by the payer. The practice did not appeal the denials.

Experienced coders are shaking their heads as they read this. They know that the (E/M) service should have been reported with modifier-57 not modifier -25. Why? Modifier-25 is used on an E/M services on the same day as a minor surgical procedure to indicate that the E/M service was separate and distinct from the minor procedure. A minor procedure is defined by Medicare––and this is accepted by all commercial payers—as a procedure with 0 or 10 global days. The global days are found in the Medicare Physician Fee Schedule and available in many coding programs. A major procedure is a procedure with 90 global days. An initial evaluation prior to a major surgical procedure is always payable. When this initial evaluation results in the decision for surgery on that calendar day on the next calendar day, append modifier -57 to the E/M service.

Key points to remember:

  • Use modifier -25 on an E/M service provided on the same day as a minor procedure. Remember, the NCCI edits require that the E/M is separate and distinct, that the physician or NPP needed to evaluate a condition prior to the decision to perform the procedure. Payment for the decision to perform the procedure is included in the payment for the procedure. For example, if an evaluation for bleeding and anemia results in the decision for an endoscopy. Report both the E/M and the endoscopy.
  • Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery.
  • Appeal denials up to the Medical Director of the plan. A surgeon should always be paid for the E/M prior to an urgent/emergency surgery.
  • Do not append modifier -57 on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service.




Not billing consult codes? You are losing $$$$

In 2010, Medicare stopped recognizing consultation codes. In their discussion, they stated that they still did pay for consultations, but they used other codes to pay for them such as office visits, emergency department visits, and initial hospital services. Practices adjusted to this change, and continued to bill Medicare for services. Some groups stopped billing all consults, thinking that the private payers would follow Medicare’s lead. This was a mistake. In many States and localities, commercial payers still recognize and pay for consultations using the outpatient and inpatient consultation codes. If you are not billing consultation codes to your private payers, you are losing money.

Someone in your practice needs to verify which payers still accept consultations. I did a presentation recently to a group of surgeons and their staff members and most of the practices said that their commercial payers still accepted the consultation codes and paid for those visits. Half a dozen people in the room were billing no consult services and these people were the same state and billed the same payers as the others. Essentially, they were losing their practices money because they did not bill for consultations.

Consultations have higher work relative value units (RVUs) and higher total payments than new patient visits or established patients visits. (See the chart at the end of this article) The definition of the CPT book says the consultations may be billed for new or established patients. If the practice is reporting new patients in place of consultations, there is a small but significant decrease in RVUs and payment. But if the patient is established to the practice and the practice must report established patient visits, there is a large and significant difference in work RVUs and payment. All specialty practices need to review this.

What insurances don’t pay for consultations? Medicare fee for service, Medicare replacement plans and most managed Medicaid programs. There are still some state Medicaid programs that do pay for consults but these are fewer and fewer. Many commercial payers recognize and pay for consults—have I mentioned that?

 Let’s look at the rules regarding consults. Since Medicare no longer recognizes consults, any old Medicare guidance about consults is no longer relevant. The rules related to consults are found in the CPT book and in other CPT references. According to the CPT book , “A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” This definition of a consult was amended in 2010 when Medicare stopped recognizing consults. Notice that it still requires a request from another healthcare professional.   CPT says that physician or NPP may perform a consult to “determine whether to accept responsibility for ongoing management of patients entire care for the care of the specific condition or problem.” That is, I a consult can be billed for an evaluation to determine whether to accept the character patient.

As I mentioned earlier consultations may be reported for new or established patients. The consulting clinician may initiate therapeutic treatments or order diagnostic tests and still bill a consult. A service requested by a family member is not considered a consult. A request for a consultation may be verbal or in writing and must be documented in the patient’s medical record by either of the requesting or consulting physician/NPP. A written report of course is required. Here is the CPT exact language about that. “The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source. “

CPT introduced the concept of transfer of care in 2010. It’s stated that if there is a transfer of care visit is no longer a consultation. I’m going to quote the CPT description of transfer of care, and then give a few examples of instances in which there is a transfer of care and a consultation would not be billed. CPT says “Transfer of care is the process whereby a physician or other qualified health care professional who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician or other qualified health care professional who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician or other qualified health care professional transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate. Consultation codes should not be reported by the physician or other qualified health care professional who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service.”

Remember that one of the first statements in the CPT book about consultations is that a physician may report a consultation to determine whether to accept the care of the patient.

Examples of transfer of care:

  • Physician is called at home by the emergency department doctor about a patient and does not need to see the patient in the ED. The physician instructs the ED doctor have the patient call the office for an appointment. This is a transfer of care, not consultation from the emergency department physician. Bill a new or established patient visit.
  • The patient is seeing an oncologist in Philadelphia and moves to Harrisburg. The Philly oncologist transfers the care to the new oncologist in Harrisburg. The physician in Harrisburg does not bill for a consultation.
  • In a single specialty group, there are only rare instances of consultations. Although physicians in a single specialty group may have different areas of expertise, transferring the patient from one physician in the group to another is rarely a consult.

One word about the word “referral.” Some coders think that if the word “referral” is used then it can’t possibly be a consult. I’m not sure what the origin of this is. Look at the CPT book’s editorial comments for the current rules related to consult. There is nothing there that differentiates between referral and consult. There is a differentiation only for transfer of care, described above.

In summary:

  • A consult requires a request from another health care professional for a new or established problem for your evaluation, assessment or opinion
  • After service is provided, a report is returned to the requesting clinician
  • Document request in the medical record
  • Transfer of care is not a consult
  • Consults are not defined as new or established

If the service does not meet the requirements of consultation, or if the payer does not recognize consultations then report the service as a new or an established patient visit in the office.

 CPT definition:

“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the exactly same specialty and subspecialty who belongs to the same group practice within the past three years.”

CMS definition:

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Questions to ask?

  • What specialty code did you use when you enrolled in Medicare and private insurance?
  • Are all of your partners in your group the same specialty?

Have you or has one of your same specialty partners had a professional service with this patient in the past three years, in any location, for any problem?

An established patient is a patient who has been seen by you or your same specialty partner (in your group) for any problem, any location, any face-to-face service in the past three years.

  • Use for office services out of global period.
  • Whether or not the patient has a new problem is not a factor.
  • Specialty designation is key.

The reason that groups stopped billing consultations was that it was difficult to keep track of what payers paid for consults and what payers didn’t. Physicians did not want to be responsible for remembering what insurance the patient had and what category of code to select. Groups that have successfully continued to report and bill for consultations usually have the physician or NPP select a consultation code if the criteria for a consultation are met. Then, behind the scenes there are edits that stop consultation codes from being submitted if the payer doesn’t recognize consults. The staff or the system can cross walk the consultation code to the correct category of code. In the office, this is a new or established patient visit. In the hospital it is an initial hospital service or emergency department visit.

Not billing for consults? Take another look.


New patient visits
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99201 0.48 0.75 1.23
99202 0.93 1.43 2.1
99203 1.42 2.17 3.04
99204 2.43 3.67 4.64
99205 3.17 4.77 5.82
Established patient visits
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99211 0.18 0.26 0.56
99212 0.48 0.71 1.22
99213 0.97 1.44 2.05
99214 1.5 2.21 3.02
99215 2.11 3.13 4.07
Office/outpatient consults  
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99241 0.64 0.92 1.34
99242 1.34 1.93 2.52
99243 1.88 2.7 3.45
99244 3.02 4.34 5.16
99245 3.77 5.37 6.29


CMS Updates, TCM, CCM and ACP

At CMS’s Open Door Forum on April 13, 2016 CMS noted there were updates to the Frequently Asked Questions documents for Transitional Care Management, Chronic Care Management and Advance Care Planning. The CMS staff discussed these and answered questions about them. I’ve written about all three topics on this blog, and you can read about them in more detail. At the end of this article, I’ve attached the links to the CMS documents. I strongly recommend that you download and read these three resources. Here are some highlights.

TCM: CMS affirmed that a practice may bill for TCM on the day of the face-to-face visit, without waiting for the 30 day period to pass. Use the place of service in which the visit took place. The biggest change? CMS is following CPT rules about attempting (but failing) to have phone or other direct contact in two business days from the date of discharge. “If two or more separate attempts are made in a timely manner and documented in the medical record, but are unsuccessful, and if all other TCM criteria are met, the service may be reported. We emphasize, however, that we expect attempts to communicate to continue until they are successful, and TCM cannot be billed if the face-to-face visit is not furnished within the required timeframe.”

TCM and CCM in the same month: It is possible to report TCM services in the same month as CCM if and only if a) the 30 day TCM period ends before the end of the month, and b) 20 minutes of CCM time is provided between the end of the TCM service and the end of the calendar month.

CCM: In order to report CCM, individuals who are providing the 20 minutes CCM time need access to the patient’s medical record. However, CMS has clarified in this new document that the access must be to the care plan, not the entire record. “This article alerts providers that the Centers for Medicare & Medicaid Services (CMS) revised the Medicare Learning Network® Fact Sheet on CCM services (ICN 909188, released in March 2015) to clarify Medicare’s requirement for 24/7 access by individuals furnishing CCM services to the electronic care plan rather than the entire medical record.”

CMS continues to defer to CPT in the definition of clinical staff, and to refer to the Medicare Benefit Policy Manual for incident to guidance. Supervision of staff for CCM and TCM is general, not direct. That is, the physician or other billing provider does not have to be in the suite of offices when the service is performed.

A practice may bill for CCM on the date the twenty minutes in the month is achieved. The practice doesn’t have to wait until the end of the month to report CCM.

Advance Care Planning: 99497 and 99498 are time based codes, and CMS has affirmed that they follow CPT time rules. That is, in order to bill the code you need to have reached over half of the time listed in the code. To report 99497, the provider must have spent 16 minutes with the patient; to report 99498 the provider must have spent 46 minutes. CMS affirmed that this can be done by as a team service, if the physician or non-physician practitioner start the discussion with the patient. This does not mean medical assistant! But, a social worker or someone with palliative care experience could work with the patient in addition to the physician. CMS is clear that this is a provider service.

If you are performing these services, or thinking of performing them in your office, download and read the articles. They consist of frequently asked questions Medicare has received about these services. If you have a question, there is a good chance it is asked and answered in these three documents.





Clues that your SCRIBE is in DISGUISE

Scribes in medical practices are in the news as a way for physicians to more effectively care for patients and use their EHRs. The scribe enters the exam room with the physician and does all of the data entry or typing while the physician takes the history, does and describes out loud the exam and develops the treatment plan with the patient. The scribe doesn’t interact directly with the patient at all, and probably isn’t the medical assistant who roomed the patient. The scribe writes, “Scribed by Betsy Nicoletti.” The physician reviews the scribed note, edits it and signs it.

 But, sometimes, medical practices don’t understand the concept of a scribe. Here are tell tale clues that the person who is “scribing” isn’t really a scribe.

  • Instead of saying, “Scribed by Betsy Nicoletti” the note says, “Dictated for Dr. Palmisano.” Huge warning sign!
  • Your scribe is disguised as a student: Medical student services are never billable services, and a medical practice can’t use the student documentation as a basis for submitting a claim to an insurance company. It usually isn’t the model for students. The student doesn’t sit and type while the clinician asks questions and examines the patient, as a scribe does. In case you need more information on this, page down to my most recent post. This relates to PA and NP students, as well.
  • Your scribe is disguised as an NP or PA or physician with an advanced degree: But, the practice has neglected to enroll the PA or NP with insurances because the medical professional is “only filling in for this week” or “really never works on his/her own.” This is an enrollment issue. Medicare and Medicaid enroll physicians, NPs and PAs, so get them enrolled and report the services appropriately. Contracts with commercial insurers vary. In some models, the PA/NP sees the patient first, does the bulk of the documentation and then the physician arrives and does a briefer visit. Report that service under the PA/NP provider number. “Dictating for Dr. Orthopedist” is not scribing as defined above and does not allow you to report the service under Dr. Orthopedist’s NPI.
  • Your scribe is disguised as an NP or PA and is doing a procedure that typically only a physician or NP or PA would do. Re-read the above example. Your PA/NP may perform procedures independently or incident to. If independently, report under the NP/PA provider number. If incident to, be sure the Medicare incident to rules are met.
  • Your scribe is disguised as you, in the room without you, asking questions or doing an exam, disguised as an independent practitioner: Scribes are typically medical assistants trained to work with a clinician as a scribe in the room. They don’t ask questions, do a physical exam or formulate a tentative plan. They don’t interact with the patient. A scribe is like a fly on the wall, recording what happens in the exam room.

If you are using scribes, that is a terrific way to unchain a physician from data entry. But, look at the list above and make sure your scribe is really a scribe. Don’t use the concept of scribing as a way to not enroll eligible professionals.

Tell me something I don’t know: confusion in reporting Psychiatry services

CMS recently released a MedLearn Matters article about coding for psychotherapy and evaluation and management (E/M) services on the same day. This article reported that the comprehensive error rate testing contractor (CERT) had found a high error rate when E/M services and psychotherapy are reported together. Tell me something I don’t know.

 In 2012 physicians, nurse practitioners, physician assistants and clinical nurse specialists working in psychiatry reported medication management with code 90862. That code was deleted in 2013. Medical practitioners working in psychiatry who performed medication management were instructed to report the service with E/M codes. If psychotherapy was provided there were new add-on codes for psychotherapy reported with medical evaluation services. The CPT book instructed clinicians not to use the time spent for the E/M service to determine the level of service for psychotherapy. While psychotherapy codes are time-based codes, E/M services may be reported either based on time (unless provided on the same day as psychotherapy) or based on the three key components of history, exam, and medical decision-making. It was all very confusing to medical clinicians working at psychiatry.

 The MedLearn Matters article tries to clarify this. “The main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services. The correct E&M code selection must be based on the elements of the history and exam and medical decision making required by the complexity/intensity of the patient’s condition. The psychotherapy code is chosen on the basis of the time spent providing psychotherapy.” That is, select the E/M service based on the history, exam, and medical decision-making documented and add a note “After the E/M service, I spent XX minutes in psychotherapy with the patient.” Describe the psychotherapy.   The article further stated that it needed to be clear that the time spent in psychotherapy did not include the time of the E/M service.“Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.”

Clinicians tell me that this is a false delineation, and that there is no easy way to mark when the E/M service stopped and the psychotherapy started. But, these are the coding rules that we have in 2014. What is a medical clinician working in psychiatry to do?

Providing medication management or medical evaluation only: if this is the only service provided a clinician may use time or the three key components to select the code. If psychotherapy is not done on the same day, and the visit is dominated by counseling, a clinician may use time to select the code. The CPT describes counseling as dominating the visit when over 50% of the time of the total visit time is composed of discussion of the diagnosis, prognosis, risks and benefits, importance of compliance, and patient or family education. In that case, document the total time and that more than 50% of the time was spent in counseling. “I spent 20 minutes with the patient over half of the discussing the side effects of medication and the other issues above.”

Only psychotherapy is provided: if only psychotherapy is provided and there is no medical E/M, use the psychotherapy standalone codes based on time. These codes are hurt 90832, 90834, and 90837. Document time in the record and describe the psychotherapy that was performed.

When both an E/M services (such as medication management) and psychotherapy are provided on the same calendar date: in this case report both an E/M service and an add on psychotherapy code. Select the level of service based on the history, exam and medical decision making. Then, document the time spent in psychotherapy not including in it the time it took to provide the E/M service.. I suggest documenting the patient’s subjective report, the mental status exam and the assessment in the plan. Then note “after the E/M service was performed I also provided XX minutes of psychotherapy.” Describe the nature of the psychotherapy. Do not document the total time of the visit because that includes both the E/M service and the psychotherapy.

Although most clinicians don’t want to read the CPT book, the section about psychiatry codes includes important editorial comments and instructions for use of the codes. Because there was such a major change in 2013, and Medicare has identified a high error rate for these services it is important for someone in the office to review this section of the book. It will only take 15 or 20 minutes to read through the editorial comments in the psychiatry section and the reward will be an increased understanding and higher coding accuracy.