NAMAS Webinar Q&A: Hodge Podge and E&M Q&A, 06/22/2021

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 June 22, 2021. These questions have been answered by the webinar presenters, Stephanie Allard, CPC, CEMA, RHIT and J. Paul Spencer, COC, CPC. If you want to listen to the webinar recording for the questions that were answered in session, please use this URL: https://attendee.gotowebinar.com/record ... 0756508942

Question 1:
Can we bill psychotherapy CPT 90832 and nursing facility CPT 99309 on same date by different providers but same tax id#, or would we be billing CPT 90833 and 99309 which looks like same provider?
Answer 1:
No you would have to use the add-on code 90833 as CPT 90832 is bundled with 99309 and never separately billable.

Question 2:
I have providers who want to charge a sick E/M code found during a well exam. Example: Parent states in the history that the child has a runny nose pulling at ears and diagnosis with Ear Infection but goes ahead and does the complete well exam. His argument is that since the medical necessity is the decision making, he should be able to bill both. How would you handle this?
Answer 2:
If he is managing the problem separately then yes I would give credit and bill separately. For example a cough and sore throat with negative strep test and supportive care with OTC meds.

Question 3:
If a provider orders and the tech does a xray in office but the equipment is owned by the hospital how do we count it? The provider always go over and gives their opinion but then it is sent to the hospital rad to read. What do we give the provider credit for?
Answer 3:
In this situation it looks as if the entire tech and pro fee (interpretation) portions of the x-ray charge are billed externally. If that is the case you can give credit once so for either the order OR review

Question 4:
If during a visit the cardiologist orders a future echo, we don't know when/if/where the patient will have the echo performed and we don't know who will be billing for the professional component of the echo, whether the same provider or whether an external provider. In the meantime, for the E/M, do we give ordering credit for the echo?
Answer 4:
This can be difficult. I personally have not given credit if the practice has the equipment and regularly provides the service. I would suggest that the practice or organization discusses this type of scenario and decide what they are comfortable with from the compliance risk perspective.

Question 5:
The data elements reviewed from previous DOS prior to 2021 should be acceptable?
Answer 5:
Yes, but you need to be careful to give credit once. I have seen providers carrying notes forward and the same exact lab results are in every visit for 2021.

Question 6:
I have a doctor that does use his QHCP as scribes. There is no rule against this financial stupidity is there?
Answer 6:
There isn't a rule for it, but chances are very high that it's a good way to burn through NPs and PAs.

Question 7:
Working in an SIU, we question the authenticity of risk when we are reviewing multiple records that have the same macro statements.
Answer 7:
I agree that make is difficult, this is definitely when I look for the provider to document additional free texted information to show what is a risk specific to each patient.

Question 8:
Would the ordering of a Cath procedure for a patient who has symptoms/risks due to commorbidities be considered high?
Answer 8:
Yes I do think that could be considered high as long as the note clearly shows the risk based on the commorbidities and not just a list that they have for example diabetes and are going for surgery.

Question 9:
How would you count medication dressings applied in the clinic for wound care and documentation of the DME Rx?
Answer 9:
If it is a prescription then the provider should document that or sometimes the EMR even shows it when the provider enters their order. If it is a product that the patient does not have access to OTC then yes I do think you could count that towards prescription drug management.

Question 10:
Do you consider oxygen a prescription drug or supply?
Answer 10:
That is a bit of a gray area, but I think if you do not count it as a prescription you could still get a moderate level of risk as a treatment option. So either way it would be moderate in the third column of the MDM grid.

Question 11:
Does COVID factor in the MDM, making the E/M levels higher?
Answer 11:
Not necessarily. The patient could have a positive COVID test and not have a lot of symptoms or severe symptoms. This is a situation where each encounter has to be considered separately and based on the documented status of the patient. I have seen some providers automatically go to moderate or high level presenting problem due to a COVID diagnosis, but it still depends on how they are documenting the severity and we cannot base our decision on the type of condition alone, it is instead of how the patient is impacted by it.

Question 12:
Another attendee asked:
Q: If a provider orders and the tech does a xray in office but the equipment is owned by the hospital how do we count it? The provider always go over and gives their opinion but then it is sent to the hospital rad to read. What do we give the provider credit for? You would count that in the same way you count an external x-ray you can give credit for the order or review only, not both.
A: In this situation it looks as if the entire tech and pro fee (interpretation) portions of the x-ray charge are billed externally. If that is the case you can give credit once so for either the order OR review Yes! correct
My follow up question to that answer is, why wouldn’t it qualify as category 2 independent interpretation of tests? This exact scenario happens frequently in our orthopedic office.
Answer 12:
It depends on whether or not your provider actually does their own interpretation. If they review and summarize the report from the hosp then it only counts as a review. If they review the actual image and write up their own interpretation then they can document their personal interpretation and get credit for that.

Question 13:
Is there a limit to the number of units that can be billed for 99417? What documentation is required to report E&M using time?
Answer 13:
There is a limitation of 4 units based on the MUE policy, but I would still bill what is supported in the note. Billing based on time requires the total time to be documented with an explanation of medical necessity to support the extended time and an overview of what tasks were done during the time.

Question 14:
Could you give guidance on fractures of foot or hands... as low or moderate regarding MDM & or risk. most of the accts that i see have no rx given & ortho contact is given
Answer 14:
It depends on whether or not the provider shows there are complicating factors. So for example a straight forward fracture that is casted and supportive treatment is advised typically supports Low MDM. The opposite of that may be a fracture that is more complicated and it is not clear if surgery will be required or just supportive casting would be more complicated and support Moderate MDM. A decision on surgery would also support Moderate MDM.

Question 15:
Depression codes-when the code says "single episode" does that mean only use it once? How do you code for months of treatment?
Answer 15:
That is a clinical decision the provider would have to make. Only code if they add that into their note.

Question 16:
Example of rapid strep, covid and urine test preformed in house: can this all be credited as Moderate in colume 2?
Answer 16:
Yes that is three separate lab tests so you would get 3 points under Category 1 in the second column.

Question 17:
If the PA and MD go in separately can you aggregate their time?
Answer 17:
When a physician and other qualified health care professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).

Question 18:
For the 2021 Time based E/M if the provider states: time spent was 29-33 minutes, how would that be billed? 99213 or 99214?
Answer 18:
They need to document one specific time spent on the date of service. If they document a time range you will have to go with the lowest time documented. In this scenario it would be 29 minutes and 99213.

Question 19:
For Time-based coding, in addition to putting in the note, should it state "Total time ___ min spent documenting, ordering tests"
Answer 19:
Yes that statement should be in the note and the note has to also support medical necessity for the extended time spent.

Question 20:
Per the question: Can you please clarify how to differentiate between minimal and low risk of morbidity since there are no examples in the chart: I go back to the TOR; would you agree?
Answer 20:
So this has been tricky this year to an extent I do look at the old TOR, but for example if they require work up with labs or x-rays I count those as low.

Question 21:
POC tests, I missed what your discussion was...We have providers who do flu tests, streps test etc in the clinic they order the test and it is performed and resulted in the clinic. Can they provider get points for ordering the test?
Answer 21:
Yes they get points for the order of those tests under category 1 in the 2nd column.

Question 22:
Is there a definition for "near term"? Acute or chronic illness or injury that poses a threat to life or bodily function ?
Answer 22:
Think of that as “near future” instead of near term. How bad would the patient get if they do not receive treatment right away? An example would be a patient who requires meds and treatments, but instead leaves the office against medical advice and does nothing.

Question 23:
May shared services be done based on MDM or Time?
Answer 23:
When a physician and other qualified health care professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).

Question 24:
May CPT 99358 be used on a different date that the visit with 99202-99215?
Answer 24:
Yes that can be on a different date.

Question 25:
NGS has indicated for "unique source" if same tax ID but different specialty/subspecialty we can count for the test, records, etc.
Answer 25:
You can count a review of external records from a unique source, but you cannot count the review of a test towards the order/review bullet point.

Question 26:
Question on electronically signing records. Does the statement "electronically signed by" or something to that effect -with the date_ have to be on there? Or can they just sign off by signing-John Doe MD? I believe it needs to be on there but I have not been able to find anything in writing that states it MUST be on there.
Answer 26:
You will want that default language from your EMR and they do typically state electronically signed or use language that shows it’s the signature. You would not want just the name of the provider typed out.

Question 27:
What if lab results are just documented in the note, with no comments. When the physician signs the note, does that give him credit for the reviewing?
Answer 27:
Do not give credit for those. A lot of EMR systems automatically add the results or allow the provider to pull them in. They have to document and acknowledge whether or not they reviewed them to give credit.

Question 28:
When an MD/DO leaves/retires from the practice and those pt's go to another MD/DO within that practice, it would be correct that the "new" provider would not get any reviewing/interpretating credit for any unique tests, etc., correct? But perhaps billing based on time would be most appropriate for visits like that?
Answer 28:
That is correct it is within the same practice or TaxID so they cannot get credit for that. Yes billing based on time would be a better option.

Question 29:
When billing an E/M with an IPPE or AWV, what constitutes medical necessity for the E/M?
Answer 29:
A new complaint that requires diagnostic testing and/or treatment or management of an existing condition.
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