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Shared Visits in the Hospital for Medicare
I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the level of E&M I recommend?
Question:
I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the level of E&M I recommend?
Answer:
No, the documentation of time is not required if Time will not be a determining factor in E&M code selection.
CMS has delayed the implementation of Time as driver for defining the substantive part of the shared encounter until January 2024.
The following excerpt is from the Final Rule published in November 2022.
Page 212:
“After consideration of public feedback, we proposed to delay implementation of our definition of the substantive portion as more than half of the total time until January 1, 2024. We continued to believe it is appropriate to define the substantive portion of a split (or shared) service as more than half of the total time, and proposed that this policy will be effective beginning January 1, 2024….”
You may consider working with your providers to start documenting time should CMS move forward with a final implementation of Time as the driver of substantive time in 2024. This would allow them to become familiar with including this in their notes, while informational at this time, if the code is to be selected on the MDM and not time.
*This response is based on the best information available as of 07/06/23.
History of Skin Cancer
If the patient is coming in for a skin examination and they have a history of skin cancer, is the complexity of the problem addressed low or moderate. We are having a debate in our office about this. The coders feel it is low when this is the only problem addressed but the doctors tell us the complexity is moderate since this is a chronic condition.
Question:
If the patient is coming in for a skin examination and they have a history of skin cancer, is the complexity of the problem addressed low or moderate. We are having a debate in our office about this. The coders feel it is low when this is the only problem addressed but the doctors tell us the complexity is moderate since this is a chronic condition.
Answer:
Yes, a history of skin cancer is considered a chronic condition, but if there are not other problems addressed and the patient currently is doing well with no reoccurrence of skin cancer the complexity of the problem addressed is low. Based on the medical decision-making table for 2021, a chronic stable problem is low, but a chronic problem inadequately controlled, not at treatment goal, etc. is moderate. The coders are correct if this is the only problem addressed during the encounter the complexity of the problem is low. But keep in mind that this one of three elements. The amount and/or complexity of data to be reviewed/analyzed and risk are the other two elements to consider. Code selection is determined by two of three elements on the MDM table which must be met. This table can be found on: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.
*This response is based on the best information available as of 06/08/23.
Billing for a Repair immediately Following Mohs Surgery
Can we bill for a simple repair when the surgeon performs Mohs?
Question:
Can we bill for a simple repair when the surgeon performs Mohs?
Answer:
An intermediate or complex repair, flaps or grafts may be reported in addition to MMS. The simple repair is included in the procedure and is NOT reported.
*This response is based on the best information available as of 05/11/23.
Mohs Surgery Question
We are having difficulty determining what needs to be documented in the Mohs procedure not to make sure we are compliant with our documentation.
Question:
We are having difficulty determining what needs to be documented in the Mohs procedure not to make sure we are compliant with our documentation.
Answer:
The procedure note for Mohs Surgery should always contain
- Indication for procedure
- Biopsy results
- Location of lesion
- Number of lesion(s)
- Size of the lesion(s),
- Number of stages performed
- Number of specimens per stage
- Type of closure
In addition, the first stage must describe the histology of the specimens taken including:
Depth of invasion
- Pathological pattern
- Cell morphology
- Perineural invasion/presence of scar tissue (if applicable)
*This response is based on the best information available as of 04/13/23.
Skin Cancer Screening
What is the correct CPT code or CPT code range for skin screening exam for lesions suspicious of skin cancer?
Question:
What is the correct CPT code or CPT code range for skin screening exam for lesions suspicious of skin cancer?
Answer:
It would NOT be appropriate for a dermatologist to report a code from the Preventive Medicine range (CPT 99381-99397) because a dermatologist is a specialist. If a patient comes in for a “routine” skin check, this should be coded with a problem-oriented E/M code (99202-99215). Also keep in mind most payors only cover a preventive visit one time per calendar year which is typically performed by the patient’s primary care practitioner.
*This response is based on the best information available as of 03/16/23.
What does “Separate Procedure “mean in a CPT Code Description?
What does “separate procedure” mean when it follows a CPT code description?
Question:
What does “separate procedure” mean when it follows a CPT code description?
Answer:
Per CPT :Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.” The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.
However, when a procedure or service that is designated as a “separate procedure” is carried out independently or considered to be unrelated or distinct from other procedures, report the code in addition to other procedures/services by appending modifier 59 to the specific “separate procedure” code. This indicates that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).
What does this mean in practice? If a code description includes the term “separate procedure”, if that procedure is in the same anatomic area as a more comprehensive procedure (for example, lyse of adhesions followed by a colectomy) only the more comprehensive procedure, the colectomy, is reported.
*This response is based on the best information available as of 02/16/23.