NAMAS Webinar Q&A: Hodge Podge and E&M Q&A, 02/23/2021

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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Below are the questions received during our recent webinar, Hodge Podge and E&M Q&A, originally presented on February 23, 2021. These questions have been answered by the webinar presenters, Shannon DeConda, CPC, CPC-I, CPMA, CEMC, CEMA, CRTT, and Stephanie Allard, CPC, CEMA, RHIT

Question 1:
So if the dr orders lab work, ct and xrays and the patients comes back for a follow up to discuss the results, I cant give credit for the doctor reviewing each result? I understand if they ordered a test day of and reviews it same day they can only get credit for one. But what about follow up visits?
Answer 1:
You will not be able to count it if your provider/practice billed for the tests. You would want to look towards the presenting problem and the treatment options or additional work up to support your level of E/M

Question 2:
Would the documentation of the prolonged service be included in the free txt box of the claim also?
Answer 2:
there is no need to that unless your MAC requires that

Question 3:
What about Co-management regarding Maternal fetal Medicine with patient with seizures in last 30 days on Keppra, wouldn't that be affecting the MFM MDM on how they are treating a pregnant patient raise the risk for co-management?? If that makes sense.
Answer 3:
Co-mananagement would not impact- still prescription drug management- still moderate risk

Question 4:
If the provider orders tests prior to the visit (without a face to face) and reviews the test results during the visit. Would he get credit for the review?
Answer 4:
Not if they are separately billing for the tests

Question 5:
Would we count as drug management the injections of a drug or vaccine given in the office since it has it's own HCPCS code and administration code?
Answer 5:
Yes- that is a prescriptions drug- so yes

Question 6:
We checked with our WPS (our Mac) and they told us we could not count the ordering of the test in Data if we were billing a CPT code for this because that would be double dipping.
Answer 6:
Yes- your MAC has the "right" to vary their opinion. i would suggest getting that in writing if possible

Question 7:
If a patient presents for a Foley change or a urine analysis, what would be required for a nurse to bill a 99211 and could you give an example?
Answer 7:
Yes- that would be depending on the documentation. the nurse should document why the patient is there a brief overview and a plan of what is being done. other examples include weight checks, bp checks, etc...

Question 8:
Would monitoring Insulin count towards drug management?
Answer 8:
If the provider is prescribing it- it wouldn't be if someone else is and they are just mentioning it

Question 9:
If our doctor utilizes a scribe is that still ok if he wants to bill total time?
Answer 9:
You would only be able to count the time spent personally by the physician

Question 10:
For infusion - are you referring to infusion at the doctor's office?
Answer 10:
Yes, we are

Question 11:
When a provider documents total time with >50% spent on coordination of care, how can you justify the time when the medical record documentation shows cloning/copying/pasting or templating of the ROS and Physical Exam?
Answer 11:
Counseling and coordination of care is no longer required and we no longer score those copied components- then i think it wouldn't matter....

Question 12:
What if you are reviewing older records from 2018-2020 for an audit?
Answer 12:
the new guidelines don't give credit for review of old records- only review of testing

Question 13:
How do you prove the non-face-to-face time in Urgent Care specialty?
Answer 13:
Really the same as any specialty. and remember- we prove anything based on documentation

Question 14:
With respect to an earlier question, aren’t all physicians in the same group considered one so you wouldn’t bill the review?
Answer 14:
Yes, but also this is not billing, but this just giving credit within the E&M

Question 15:
Do we need to itemize or breakout the individual activity in the TIME?
Answer 15:
There is no requirement, but it would be best practices.

Question 16:
In order to support the med management for continue meds, shouldn't the dosage be documented? Some providers just say continue current meds, with no indication of what those meds are.
Answer 16:
Yes, definitely the note should support what meds they are deciding to continue, that should not be assumed by the coder/auditor

Question 17:
Since we cannot count the ordering of a test in our office (per our MC carrier) would you consider the ordering of a PET or Nuclear to be moderate risk when ordered by a cardiologist?
Answer 17:
Yes, I would use that as moderate under the 3rd column for the risk of morbidity based on the diagnostic test

Question 18:
Cardiologists documents that patient has emphysema. He is not treating it. However, can it be considered in the risk for the patient when ordering tests, treatment, etc.?
Answer 18:
It can be considered a risk if the provider addresses it as a risk. But. if the provider doesn't- then it wouldn't if it were just listed.

Question 19:
What if an RN does training on injecting insulin? Does this count toward total time since it isn’t billable?
Answer 19:
No, because the RN time cannot count toward the encounter time- only the clinician time

Question 20:
What if they are being sent to the ED only because the office doesn't have the equipment to treat a problem that may not be high risk?
Answer 20:
No, that would not be

Question 21:
Is there anywhere to count REFERRALS to other practices for continuation of care anywhere in the MDM?
Answer 21:
Well, not written out, but in reality, remember that the clinical examples in column three are merely examples and not hard fast criteria

Question 22:
Back to the counted labs. I have taken a few webinars and every single one has said that if you perform the test/lab/ekg and it can be billed separately, we can't count it towards the MDM. So you are saying that it's not true. You CAN count them?
Answer 22:
The guidelines do not clearly give direction on this. We are stating you can count the order of the testing, you would not be able to count review of the test or independent interpretation

Question 23:
Would injection of a drug such as kenalog be counted as prescription drug management?
Answer 23:
Yes- it is an rx drug

Question 24:
Do you agree that it is not a lot easier to code 99214? For example, chronic htn not at goal, med increased. This is a 214 if appropriately documented.
Answer 24:
Yes- i agree- that is a 4 all day long!

Question 25:
Are Commercial Insurance companies or even CMS allowed to dictate which Guidelines are used to audit E/M services, other than Office and Other Outpatient visits?I work as an auditor and one of our VPs brought this to my attention.I believe providers are allowed to choose which guidelines 1995 / 1997. except for 2021 Outpatient and Other Office Visits.
Answer 25:
CMS has a policy where its carriers are required to use whichever guidelines (1995 or 1997) would best support the provider’s reported code level, excepting the outpatient/office E/M codes which use 2021 guidelines, period. However, some CMS carriers still had their own LCDs on E/Ms, such as Novitas requiring a 4x4 exam regardless of 1995/1997 guidelines. So it’s best to check the carrier’s LCD guidance. As for commercial payers they have complete freedom to use whatever guidelines they want. Commercial payers dictate to providers what they will and will not accept, not the other way around. That said, virtually all commercial payers follow CMS in allowing either 1995 or 1997, and in following only 2021 for office/outpatient E/M codes.

Question 26:
How would you explain to a provider that when coding telehealth OV 99212-05, they can only be audio and video, not audio only? I know there is everchanging guidance. The thought process I am up against is when the patient has no video access, why should this change how it is coded. I don't think I am getting through. Any advice?
Answer 26:
It depends on the payer, Medicare won’t pay 99202-99215 if it’s audio only, but many private payers will. The best practice is to research all relevant payer policies for the payers you accept, then follow through accordingly. If the patient has no video access and the payer doesn’t accept audio only, you will simply have to settle for the audio-only codes that could apply, such as G2012 or 9941-99443. Payers decide what they’ll pay for and that’s unfortunately just the way it is.You may find this guidance from AAFP helpful in delineating different commercial payer policies: https://www.aafp.org/family-physician/p ... audio.html

Question 27:
Patient had treatments for lymphoma in 2015, in remission and remains stable, labs taken and is to return in 6 months. Using the 2021, I have a stable chronic illness (Low), 1 lab (minimal). Now the question lies in risk. Minimal risk of morbidity or Low risk of morbidity from diagnostic testing or treatment? The risk level will make the code. At this time, I feel it is 99212-minimal but at the same time because he is testing the patient to be sure it hasn’t come back, does that make it low?
Answer 27:
The 2021 guidelines offer a broad definition of risk and says that “For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated.” So that means you must look at the consequences of that problem if appropriately treated. I really don’t know enough about this patient’s lymphoma to say whether the risk with proper treatment (which in this case would mean appropriate follow-up and monitoring at appropriate intervals) is minimal or low. How likely is this type of lymphoma to recur, based on the patient’s history? That is going to depend on what the provider documented, and if you are in doubt I would ask them. My gut is low, and 99213, but again I am saying this without reading the full documentation. For these types of close calls I would suggest having a discussion with the provider to get on the same page. See below excerpt from the 2021 guidelines:
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as ‘high’, ‘medium’, ‘low’, or ‘minimal’ risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization.

Question 28:
How can we determine if risk is Minimal or Low if there are no treatment options listed in A&P but they are ordering diagnostics?
Orthopedic Example: Left shoulder pain injured by fall at work, Xray performed and billed no evidence of fx. Order MRA to determine extent of shoulder injury.
Problem: Low (acute uncomplicated)
Data: Minimal (MRA shoulder - not counting xray due to billing same day)
Risk: Minimal vs Low?????? No mention of meds, pt, or anything else
Answer 28:
The guidelines include diagnostic testing as a management option. For example 99213/99203 corresponds to “low risk of morbidity from additional diagnostic testing or treatment” under the Risk column of MDM.

Question 29:
I have a physician who is asking if he can bill time based in 2021 and count the time when they have “learners” with them as the physician is still documenting details of all of the records and everything that was reviewed?
Answer 29:
I’m a little unclear what time the physician is referring to. Is this time later on the same day as the E/M encounter? A teaching physician who is supervising an E/M encounter furnished partly by a resident physician or fellow, is able count only the time they are personally present. The same would go for eligible activities in 2021 that can be counted toward time spent on the same date of the encounter when billing 99202-99215.

Question 30:
In a multi-specialty practice can 2 providers (of different specialties) bill for an office visit on the same day?  I was under the impression that this was allowed and I was also under the same impression that it wasn’t allowed.  Is this strictly payer dependent?
Answer 30:
Generally the answer is yes. Medicare’s rule is two providers of the same specialty under the same tax ID must bill as if they were one provider. So if they are different specialties they should both be able to bill. But check with your payer.

Question 31:
We are an orthopedics office and do a lot of joint injections.  We are trying to determine how they would be counted towards the MDM.  I’m not sure, because we are being separately reimbursed for them.  If we can use them for MDM, would they be considered Low-minor surgery with no identified risk factors? 
Answer 31:
The 2021 guidelines say that separately reimbursed diagnostic tests cannot count toward the data element of MDM. Separate reimbursement has no bearing on therapeutic interventions when calculating MDM. Joint injections i.e. corticosteroids fall under prescription medication management although the overall medical necessity picture is probably going to be low, and also remember that an E/M should not be separately reported when you are billing for the injection procedure code unless you can meet modifier 25 requirements and append -25.

Question 32:
When a provider is recommending a specific treatment, but then says that the patient cannot do that treatment because of a specific co-morbidity, can we still count that treatment in Risk of Complications and/or Morbidity or Mortality of Patient Management? So for example, a podiatrist wants to prescribe Lamisil for severe tinea pedis, but documents that the patient cannot take that medication due to having hepatitis. Would this still fall under Moderate for Rx drug?
Answer 32:
We would cautiously say the answer is yes, with the proper documentation. We base our opinion on verbiage in the new 2021 guidelines that state:
A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.
For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization.
In the example of the patient declining TKA, I would really encourage the provider to document a reason. It’s hard to imagine the patient not giving a reason at all, and there are many legitimate reasons such as the cost, the disinclination to go through the procedure, recovery, therapy, etc.

Question 33:
When patients present for annual preventive visits, we would not charge an additional E/M for management of chronic issues unless there was an exacerbation or a new issue. With the new guidelines, the elements are no longer overlapping and with the preventive visits MDM is not necessary. Are we able to charge an additional E/M if they present for PE and follow up of 2 chronic conditions with medication management? 99396+99214?Same question would be for the Medicare Annual Wellness Visits- I know in the final rule that they have increased the payment to crosswalk to 99214- if we are meeting all elements of the AWV's and managing 2 chronic issues with medication management, are we able to charge G0438-G0439 + 99214?
Answer 33:
First it’s important to note that history and exam are not supposed to be skipped under the 2021 rules. Instead CMS and CPT both state that a “medically appropriate” history and exam are required to support any office/outpatient E/M visit. So I disagree that a preventive visit and a problem-oriented E/M visit “no longer overlap” in terms of requirements. You cannot bill a problem-oriented E/M visit with no history and exam – unless you can argue it was “medically appropriate” to have no history or exam. And you cannot count elements of the preventive visit documentation toward the E/M visit.
Second, Medicare carriers have made it clear that the AWV includes an assessment of a patient’s chronic conditions. To quote NGS, the work of the AWV includes “All chronic conditions are individually assessed and a comment added regarding the status of each chronic condition.” NGS does say that if the chronic conditions require “additional clinical examination and review or changes to the plan of care” then it may be sufficient to support a separate E/M visit, in which case “documentation of the E/M visit should clearly support the medical necessity of the separate service.” NGS FAQ link
So the bottom line answer to your scenario about 2 chronic conditions and RX med management as part of the visit, I really think nothing has changed if there is no exacerbation or new problem. If they list the chronic conditions and say “continue plan” or something to that effect, I don’t think it meets the NGS standard of requiring “additional clinical examination and review or changes to the plan of care.” And of course, the 2021 rules are not a permission slip to get out of documenting a separate history and exam for the separate E/M visit, if one is billed – you will still need to document a history and exam that the provider would be comfortable defending as “medically appropriate.” Clearly, zero history and zero exam are not medically appropriate, so they’d need something.
Thus effectively the new rules do not represent a new and more liberal license to begin billing high-level E/M codes with preventive services like the AWV or 99396.
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Tue Mar 02, 2021 6:07 pm

You had mentioned having monthly webinars like this one to review questions that are asked by remembers. Where do we post questions for the next Hodge Podge? If here, then this is my question:

Other than an independent interpretation of a radiology image or EKG, is there any other examples where a provider would be given credit for independent interpretation? I have a provider wanting credit for this element when he reviews lab results an interprets what these results mean for his patient - I advised this may fall under review of labs (depending on who ordered &/or billed for it) as well as be considered in the problem (is it a chronic problem that based on labs is stable or unstable or diagnosis of new problem) as well as Risk (what medical management/risk documented based on the results). So wanted to verify what else may fall under Independent Interpretation other than the obvious ones mentioned above.
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