Is Documentation of HPI and Exam Necessary in Determining a level of E/M?

Question:

With the 2021 and 2023 Guideline changes, is it necessary to document an HPI and Exam when neither counts towards the level of service?

Answer:

As described in the most recent AMA E/M guidelines, documentation of a history of present illness (HPI) and an exam are no longer required to contribute to the level of an E/M service. Today, documentation of medical decision making, or time are the sole determinants supporting a level of E/M. E/M documentation should include a medically appropriate history and examination. While the nature and extent of the history and exam is to be determined by the clinician, they add to the medical necessity of the visit and provide a more complete representation of the patient condition for continuity and coordination of care with other clinical providers.

*This response is based on the best information available as of 3/13/25.

Esophageal Sphincter Augmentation for GERD

Question:

How is esophageal sphincter augmentation for GERD reported?

Answer:

Report CPT code 43284 for laparoscopic placement of the augmentation device (i.e. magnetic band). CPT code 43285 is reported for subsequent removal of the device.

*This response is based on the best information available as of 3/13/25.

Vertebral Segment vs Motion Segment

Question:

What is the difference between a vertebral segment and a “motion segment”?

Answer:

A vertebral segment represents a single vertebral bone with its associated articular processes and lamina.  A “motion segment” refers to 2 vertebral segments and the vertebral interspace (non-bony compartment between two adjacent vertebral bodies) between.

*This response is based on the best information available as of 3/13/25.

Physician Assistant Billing for New and Established Patients

Question:

Our Physician Assistant saw a new Medicare Patient in the office for evaluation of left knee pain. She evaluated the patient and developed the plan of care. The patient was scheduled for a return visit with the Physician Assistant. During the return visit, the Physician Assistant evaluated the patient and made no changes to the plan of care—she continued the NSAIDs as the patient responded well.

Can she bill this  “Incident to” the physician who was in the office, as there was no change in the plan of care?

Answer:

Thanks for your inquiry. Although the second visit involves an established patient with no changes to the plan of care or new orders, the Physician Assistant must  submit the claim as the service provider. The 'Incident to' requirements have not been met.

To move this to an “Incident to” encounter, there must be an independent encounter with the physician who either agrees with or changes the plan of care. After the physician independently evaluates the patient and either agrees with or modifies the plan of care, subsequent encounters with the Physician Assistant may be reported as 'Incident to' if the requirements are met (e.g., implementation of the plan of care without new orders or changes to the plan of care).

*This response is based on the best information available as of 3/13/25.

Layered Closure with Lesion Excision

Question:

Our practice performs many excisions of lesions with closures. My question is related to the closures. Is the provider documenting the closure in layers enough to report an intermediate repair if the tissue level is not?

Answer:

Great question!

We know that lesion excisions and closure with either intermediate and/or complex closure are appropriate to report together if the documentation supports it. In contrast, closure with simple repair is an included lesion excision and is not separately reportable.

The CPT guidelines are essential and should be reviewed carefully, as the definitions of each closure type can be found here. To report a closure accurately, it is best practice to include the type or level of tissue being repaired. KZA would encourage you to review the CPT guidelines for closures with your practice for documentation purposes. As you can see from the guidelines within CPT, the type and tissue level are factored into the definitions.

*This response is based on the best information available as of 3/13/25.

Craniectomy for Tumor Resection

Question:

Patient had a posterior fossa craniectomy for excision of a mass which was consistent with metastatic tumor. Pathology results report the mass as a partially cystic metastatic tumor.  What is the correct code 61518 or 61524?

Answer:

The correct CPT code is 61518; a metastatic tumor is still a tumor even if it is partially cystic.

*This response is based on the best information available as of 2/27/25.