Incident-to Requirements for Medicare

Question:

Thank you so much for all the information you gave out in Chicago at the KZA Convention. We always have great take-a-ways when we leave there. I do have a question for you regarding incident-to billing for Medicare.

One of my physicians is stating that her attorney told her being “under the same roof” of the building counts and you don’t necessarily need to be in the same suite. I am disagreeing stating they have to be in the same suite and even though she is available to run upstairs if needed, by her being on the second floor that goes against the “incident-to” rules. Am I correct?

Answer:

According to CMS In order to qualify as an incident-to service, there must be direct physician supervision of the NPP providing the service. Direct supervision means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. It does not mean that the supervising physician must be present in the room where the procedure is performed. Also the supervising physician must be immediately available (without delay). The supervising physician can be in another room As long as they are not performing a procedure that they cannot stop and go to help with the other patient then they are considered immediately available. CMS also clarifies that immediately available

CMS has clarified the office suite it is limited to the dedicated area or suite designated by records of ownership, rents, or other agreements with the owner.

Sources:https://med.noridianmedicare.com/web/jeb/topics/incident-to-servicesand CMS Medicare Benefit Policy Manual Pub. 100-2, Section 60https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

*This response is based on the best information available as of 06/16/22.

Coding for a Hospital Visit

Question:

I was at your conference this past weekend and I was wondering if you could clarify something for me. When a physician sees a Medicare patient in the hospital, and it is their first time seeing the patient however they are NOT the admitting physician, they can only bill a subsequent visit or consult code depending on what the payor allows and documentation correct? Thank you for your assistance.

Answer:

If the physician is seeing the patient in the hospital for the first time even though he/she is not the admitting physician based on appropriate documentation, an initial hospital visit code (99221-99223) can be billed as long as all three key component requirements are met.  If the minimum requirement for the initial hospital care code is not met a subsequent hospital visit can be reported.  Keep in mind Medicare does not pay for consultations.

*This response is based on the best information available as of 06/02/22.

Billing Additional Pre-op Visit

Question:

Since we have to bring the patients back in for COVID testing and H&P for Joint Commission, can we bill for this visit even though it’s another pre-op visit?

Answer:

Yes, since the original surgery was canceled and is now under consideration for rescheduling due to the pandemic and needs to be seen for a COVID swab prior to surgery, which is an indication for charging a new visit (as a health status change)

*This response is based on the best information available as of 05/019/22.

Vocal Fold Augmentation Injections in the Office

Question:

What code do I use for a vocal fold injection for augmentation in the office? Can I also bill for the injection material?

Answer:

Good questions! The correct code is 31574,Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateralwhen performed via flexible laryngoscopy. If you’re in place of service 11 (physician office), you would NOT separately code for the injection material (J code), to Medicare, because the payment includes the practice expense for the injection material. If you’re in place of service 22 (hospital based clinic), then your payment for 31574 will not include the injection material because the facility (hospital) will have borne the expense for that cost. Finally, if you harvest fat graft via liposuction to be injected into the vocal cord then you may separately report 15773/+15774 depending on the amount of fat injected (not amount of fat harvested).

*This response is based on the best information available as of 05/05/22.

Inpatient E/M Coding

Question:

I did an inpatient consultation and coded 99253 (non-Medicare). I did not need to follow the patient so I signed off. They asked me to re-consult a week later.  What is the code for a re-consult?

Answer:

There are no specific E/M codes for an inpatient re-consultation.  You’ll use the subsequent hospital care code, 9923x, since it’s the same admission for the patient.

Question:Follow up question: the patient was discharged then admitted a month later and I was consulted again. Is this a subsequent hospital care code?

Answer:

No, since it’s a new admission for the patient, you’ll use the consultation code again (9925x).

Question:Last question: when I see the patient in my office a month later, is it a new patient?

Answer:

No, it’s an established patient (9921x) because you’ve had a face-to-face visit with the patient in the previous 3 years.

*This response is based on the best information available as of 04/21/22.

Adjacent Tissue Transfer

Question:

A few years ago I was at your coding workshop in Chicago – you were great, Kim! I remember discussing the adjacent tissue transfer or rearrangement codes and you said we need a size dimension to code for CPT 14040 or 14041 or any of the ATT codes. Do you have a specific guideline or a resource that I can find to support this? As always thank you so much for your guidance.

Answer:

Thank you for your kind words! Sure – just look in the CPT book in the Guidelines for the Adjacent Tissue Transfer or Rearrangement codes. The last paragraph defines the terms primary and secondary defects. The CPT codes themselves are defined by square centimeters – this is the total sq cm of each defect (primary and secondary). When you use a CPT code that has a dimension in the description, such as sq cm or linear cm, then that dimension must be documented to support the billed code. It is very important for you to document the primary defect dimension and secondary defect dimensions separately. These two dimensions are added together to “equal” the CPT code.

*This response is based on the best information available as of 04/7/22.