(Medicare Claims Processing Manual)

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.  If more than one evaluation and management (face -to-face) service is provided on the same day to the same patient by the same  physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.  Instead of billing separately, the physicia ns should select a level of service representative of the combined visits and submit the appropriate code for that level.  Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. 30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery  (Rev. 954, Issued: 05- 19-06, Effective: 06 -01-06, Implementation: 08- 20-06)  A. CPT Modifier  -24 - Unrelated Evaluation and Management Service by Same Physician During Postoperative Period   A/B MACs (B) pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221- 99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier  -24, and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure.  They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery.  All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.  B. CPT Modifier  -25 - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure  Medicare requires that Current Procedural Terminology (CPT) modifier - 25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitione r) to the same patient on the same day as another procedure or other service.  A/B MACs (B) pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately iden tifiable E/M service that is above and beyond the usual pre - and post -operative work of the procedure.  Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier - 25 is added to the E/M code on the claim.  Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patients medical record to support the claim for these services, even though the do cumentation is not required to be submitted with the claim.  If the physician bills the service with the CPT modifier  -25, A/B MACs (B) pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met:   When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure;   When preoperative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure; or   When an A/B MAC (B) has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier  -25 compared to other physicians, has done a case -by-case review of the records to verify  that the use of modifier was inappropriate, and has educated the individual or group, the A/B MAC (B) may impose prepayment screens or documentation requirements for that provider or group.  When a A/B MAC (B) has completed a review and determined that a high usage rate of modifier  -57, the A/B MAC (B) must complete a case -by-case review of the records.  Based upon this review, the A/B MAC (B) will educate providers regarding the appropriate use of modifier  -57.  If high usage rates continue, the A/B M AC (B) may impose prepayment screens or documentation requirements for that provider or group. A/B MACs (B) may not permit the use of CPT modifier  -25 to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT definition of the modifier. C. CPT Modifier  -57 - Decision for Surgery Made Within Global Surgical Period   A/B MACs (B) pay for an evaluation and management service on the day of or on the day before a procedure with a 90- day global surgical period if the physician uses CPT modifier -57 to indicate that the service resulted in the decision to perform the proc edure.  A/B MACs (B) may not pay for an evaluation and management service billed with the CPT modifier  -57 if it was provided on the day of or the day before a procedure  with a 0 or 10- day global surgical period.  30.6.7 - Payment for Office or Other  Outpatient Evaluation and Management (E/M)  Visits (Codes 9920 2 - 99215)  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A.  Definition of New Patient for Selection of E/M Visit Code   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 interpretatio n 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.   B.  Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems   As for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M  office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus -outpatient hospital, or on campus -outpatient hospital setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).   C.  Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility   MACs may not pay a physician for an emergency department visit or an office visit and  a comprehensive nursing facility assessment on the same day.  Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician (see section on Nursing Facility Services below).   D.  Drug Administration Services and E/M Visits Billed on Same Day of Service   MACs must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004).  This drug administration policy was expanded in the  Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005).  Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher  complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25.  Documentation should support the level of E/M service billed.  For an E/M ser vice provided on the same day, a different diagnosis is not required.   E. Prolonged Office/Outpatient E/M Visits   When the practitioner selects office/outpatient E/M visit level using time, the practitioner reports prolonged office/outpatient E/M visit time using HCPCS add- on code G2212 (Prolonged office/outpatient E/M services). See Prolonged Services section for additional information.  F. Add -On Code for Office/Outpatient E/M Visit Complexity   Beginning January 1, 2021, Medicare established HCPCS add -on code G2211 describing visit complexity inherent to office/outpatient E/M visits associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition, or a complex condition.   HCPCS code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patients single, serious, or complex condition. (Add- on code, list separately in addition to office/outpatient evaluation and management visit, new or established)).   The Consolidated Appropriations Act, 2021 delayed PFS payment for this code until January 1, CY 2024 or later. Practitioners may report this code for qualifying visits furnished on or after January 1, 2021, although we assigned a PFS payment status indicat or of B (Bundled) until 2024.    HCPCS code G2211 includes services that enable practitioners to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single, high- risk disease) and to address the majority of patients health care needs with consistency and continuity over longer periods of time. This includes furnishing services to patients on an ongoing basis that result in care that is personalized to the pat ient. The services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve delivery of team -based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape.    Reporting is not restricted based on specialty, but certain specialties will likely furnish these types of visits more than other specialties. HCPCS code G2211 may be reported with any visit level.    Example 1: In the context of primary care, HCPCS code G2211 could recognize the resources inherent in holistic, patient -centered care that integrates the treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care in a collaborative relationship with the clinical care team.    Example 2: In the context of specialty care, HCPCS code G2211 could recognize the resources inherent in engaging the patient in a continuous and active collaborative plan of care related to an identified health condition the management of which requires the direction of a clinician with specialized clinical knowledge, skill, and experience. Such collaborative care includes patient education, expectations and responsibilities, shared decision- making around therapeutic goals, and shared commitments to achieve those goals.     Example 3: We do not expect reporting of HCPCS code G2211 when the office/outpatient E/M visit is reported with payment modifiers such as a modifier - 24, -25, or -53.   G. Medical Review When Practitioners Use Time to Select Visit Level   Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit.   30.6.8 - Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services)  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A. Who May Bill Observation Care Codes   Observation care is a well -defined set of specific, clinically appropriate services, which include ongoing short -term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further  treatment as hospital inpatients or if they are able to be discharged from the hospital.  Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring i n order to make a decision concerning their admission or discharge.