Medicare stopped paying for the consult codes [99241-99245, 99251-99255] January 1, 2010. The consult codes paid more than their corresponding inpatient follow-up [99231-99233] and outpatient visit [99201-99215] alternatives, but came with very specific, but strict and confusing, situational and documentation criteria to allow for their reimbursement. Although Medicare stopped paying for the consult codes, they did not stop paying for consult services. The concept of needing the expertise of another provider is still essential to the practice of medicine. What has changed is how those services need to be reported for reimbursement to Medicare. Some private payors still reimburse for the consult codes, using the old Medicare situational and documentation guidelines, but these numbers are decreasing. Until 100% of insurers stop paying for the consult codes [99241-99255], two different payment systems for consults exist. Thus, the same work provided to two identical patients may be reimbursed differently depending on the patient’s insurer.
MEDICARE PATIENTS AND THOSE INSURERS FOLLOWING MEDICARE CONSULT RULES
The set of codes submitted for a consult to a Medicare patient is based on several variables: inpatient versus outpatient status, disposition after being seen in an emergency room (eventual admission vs observation status vs discharge home), and whether a patient is new or established to the physician specialty and billing group. (See Figure 28-1.)
Algorithm for selecting the proper CPT code set for mediCARE consults in a hospital setting. (Copyright 2010, Yvette M. Cua, MD. Used with permission.)
Initial consults for patients in acute care hospitals and skilled nursing facilities (SNF) are billed with the same initial inpatient visit codes used for admissions [99221-99223 (initial inpatient visit), 99304-99306 (initial SNF visit)]. All subsequent consult visits are billed using the subsequent inpatient or SNF visit codes respectively [99231-99233, 99307-99310]. The final day seeing the patient as a consultant will still be billed using the subsequent inpatient and SNF codes, even if the consultant is contributing to or fully providing the patient’s discharge management. Only the admitting physician/billing group can bill for discharge management services [99238-99239]. Medicare will only pay for medically necessary visits and not just daily “routine” visits because the patient is still in the inpatient hospital or SNF.
If a new problem or question surfaces, or the consultant is reconsulted during the same inpatient admission, with or without a time lapse since the last consultant visit, a subsequent inpatient/SNF visit code [99231-99233, 99307-99310] would be submitted for this service.
If a consultant is asked to see a patient whom they provided a consult on during a previous admission, even with the same problem(s) as last admission, the consultant would still bill an initial inpatient/SNF visit code [99221-99223, 99304-99306] for this work.
In the event that the documentation for the initial consult does not meet the minimum documentation criteria for the lowest level of initial inpatient service , Medicare will allow this work to be reported with subsequent inpatient visit codes [99231-99232]. The documentation criteria for these services parallels those of the lowest two levels of consult service for the old code set [99251-99252], which explains the rationale for this practice. Keep in mind that the ability to submit an initial consult service with a subsequent inpatient visit code does not hold true for admissions. For an initial inpatient visit (ie, admission) reported by the primary attending of record, if the documentation for this service does not meet the minimum criteria for the lowest level of service , subsequent inpatient visit codes cannot be submitted for this work. This work would be reported with E/M code 99499 which means that the documentation for the service does not meet criteria for recognized E/M services. This would fall under manual review and be left up to the Medicare contractor to determine what if any payment would be given. Check with local Medicare intermediaries for deviation from this rule. At least one carrier, Noridian, as of the time of publication of this chapter, will allow use of subsequent inpatient visit codes [99231-99232] for this admission scenario.
Since more than one physician will now be submitting an initial inpatient/SNF code, the primary attending of record for the patient needs to attach modifier –AI (A “eye,” not A “one” or A “el”) to their initial inpatient/SNF service. Consultants should not use this modifier.
Occasionally, hospitalists are consulted on patients in an outpatient unit of the hospital, such as the ambulatory surgery center. Also, observation status patients are considered outpatients even though they may occupy a hospital bed in the same room as an inpatient. Initial consults for these patients are billed using outpatient visit codes [99201-99215]. Initial observation visit codes [99218-99220, 99234-99236] should not be submitted for this work. Within the outpatient set of codes are new patient [99201-99205] and established patient [99211-99215] codes. A consultant now needs to determine if a patient is “new” versus “established” to select the correct code set to use. A patient is considered “new” to an individual physician if they have not received any E/M services from any member of that physician’s billing group and specific (sub)specialty within the past 3 years, regardless of the location of the service. Note that billing for the professional component of a service, or writing an order on a patient does not affect the “new” or “established” status of a patient.
Below are some common examples to illustrate nuances with this definition.
An internal medicine consultant evaluates a Medicare observation patient on the neurology service. The consultant has never seen the patient before, but the patient was seen in the emergency room by an internal medicine partner in their billing group, moonlighting 2 years ago. This consult would be reported with an established outpatient code [99212-99215].
A hospitalist evaluates a patient in observation status at the request of the ENT service. This patient has a history of monthly admissions to the hospital medicine service for severe chronic obstructive lung disease (COPD) although not recently. The initial medicine consult would be billed using the new outpatient code set [99201-99205].
A patient, seen routinely by an endocrinologist in a multispecialty practice for years, is placed in observation status on the general surgery service with a consult request to an internal medicine hospitalist in the same multispecialty group as the endocrinologist. The patient has never been seen by the internal medicine group in the past. This consult would be reported with a new outpatient code [99201-99205].
A cardiologist read an electrocardiogram (ECG) on a patient last week and billed for the formal ECG report, but has never seen the patient before, and no one in their group has ever provided an E/M service to this patient. Subsequently, the cardiologist evaluates this patient who is being observed on the internal medicine service. The cardiologist would bill their initial consult using the new outpatient codes [99201-99205].
If a follow-up consultant visit is necessary, even on discharge day, all of these patients are now established patients, and this work would be billed using the established outpatient visit codes [99212-99215].
EMERGENCY DEPARTMENT PATIENTS
For consults on patients seen in the emergency department, the patient’s ultimate disposition will determine which set of codes to use to bill for the consult.
Admission to an inpatient service. Only one CPT code will be submitted for an evaluation by a consultant in the emergency department, followed by admission to the inpatient service, an initial inpatient visit [99221-99223]. If that patient is admitted to a different subspecialty’s inpatient service, an initial inpatient visit code [99221-99223] is still reported for this work.
Placement into observation status. If the above patient is eventually placed into observation status on the consultant’s service, only one CPT code will be submitted for both the work of the consult and the placement into observation, an initial observation visit code [99218-99220, 99234-99236]. If the patient is placed into observation status on a different subspecialty’s service, this work will now be reported with an outpatient visit code [99201-99215] based on whether they are “new” or “established” to the consultant’s billing group and subspecialty.
Discharged home. Finally, if the emergency room patient is eventually discharged home, an emergency room visit code [99281-99285] will be submitted for the work of the consult.
PAYORS WHO STILL RECOGNIZE THE OLD CONSULT CODES
For individual state Medicaid programs and for private insurers, check with plan representatives to see if they follow the new Medicare rules, or if they still pay for the consult codes [99241-99255]. For those that still recognize consult codes, check with the individual payors as well as your compliance office to see if they follow the old Medicare consult situational and documentation guidelines or if they have their own internal set of requirements.
In order to bill for a consult based on the old Medicare guidelines, several criteria have to be met. The Mnemonic “The 3 R’s” refer to these criteria. The consult has to be REQUESTED by another provider who wants the consultant to RENDER their opinion about (a) specific question(s), and the ensuing recommendations must be REPORTed back in writing to the requesting provider. The essence of a consult in this system, is that another provider seeks the opinion of a consultant with expertise above and beyond his own for a particular problem or set of problems. The concept of a “REQUEST for opinion” is stressed for three reasons (1) to distinguish it from a self-referral by the patient, which cannot be reimbursed as a consult (2) to distinguish it from a transfer of care, and (3) to prevent improper payment for “protocol” care that may not have adequate medical necessity documented in the chart. For example, if a hospital mandates that 100% of patients admitted for surgery or to a psychiatry ward must have a medicine consult, this could lead to nonbillable work. In these situations, a preprinted admission form requesting a medicine consult per “hospital policy” without documented medical necessity for each individual patient situation, would lead to nonbillable work. If a 25-year-old healthy female is admitted to general surgery for complications after an elective cholecystectomy, but has no other medical issues, there is no medical necessity for a medicine consultant to see the patient. The surgeon does not consciously request this service or have a particular question for the medicine consultant to answer, and does not need the internist’s expertise to manage the postoperative issues. A hospital mandated task is therefore not reimbursable through the patient’s insurance.
Because the consult codes reimburse higher level per level, than their subsequent follow-up counterparts, there is a big push to ensure that an opinion was requested, and not a transfer of care. This is the essence of a consult for those insurers that still follow these guidelines. For example, medical consultation request for an opinion regarding selection of anti-hypertensive medication in a pregnant inpatient would meet criteria for allowing a consult [99251-99255] to be billed, even if the recommendations include continued concurrent care of the hypertension by the internist. On the other hand, if the obstetrician is not comfortable managing hypertension at all, and wants the care of that problem to be totally managed by the internist, the essence of the request for help is no longer for an “opinion” about management. The request is for the internal medicine consultant to take over the care of the hypertension while the obstetrician continues to manage the other aspects of the patient’s care is referred to as a “transfer of care.” If the patient remains on the obstetrician’s service and the internist provides concurrent care, managing hypertension, this work cannot be reported with the “transfer of the patient to another service” consult codes [99251-99255]. In this concurrent care situation, the internal medicine consultant would report this work with a subsequent inpatient visit code [99231-99233]. For those payors who do not follow the new Medicare rules, only one initial inpatient visit [99221-99223] can be reported and reimbursed per patient per admission, thus the reimbursement for this work is substantially lower than if it were reimbursed through the consult codes [99251-99255].
The final criterion of REPORTing recommendations speaks to good medical documentation. Although a consultant may opt to call the requesting physician with urgent recommendations for good quality patient care, these recommendations need to exist in writing, accessible by the requesting physician. In the inpatient setting, the consultant note entered into a shared medical record will satisfy this criterion.
Initial consult visits to inpatients in both acute care settings as well as SNFs are billed using inpatient consult codes [99251-99255]. All subsequent visits are billed using inpatient/SNF follow-up codes respectively [99231-99233, 99307-99310].
Consults to patients seen in an outpatient area of the hospital, including observation status patients, are billed with the outpatient consult codes [99241-99245]. If a follow-up consultation visit is needed, it would be billed using the established outpatient visit codes [99212-99215]. Check with individual state Medicaid programs and private payors to see if they require the subsequent observation visit codes [99224-99226] instead, for observation status patients.
EMERGENCY DEPARTMENT PATIENTS
Just as for Medicare patients, the physical location of the patient is not what determines the selection of codes to use for billing consults. It is the patient’s “status.”
Admission to an inpatient service. For patients located in the emergency department who have already been admitted to an inpatient service, use the inpatient consult codes [99251-99255]. If the consultant admits the patient to their inpatient service on the same date as the consult, only one CPT code for the work of both the consult and the admission should be submitted—an initial inpatient admission code [99221-99223].
Observation status. If the patient in the emergency department is assigned observation status on a different service from the consultant’s, the consult will be billed using the outpatient consult codes [99241-99245]. If the consultant places the patient into observation status on his own service on the same calendar date, only one CPT code should be submitted for all of this work—an initial observation visit [99218-99220, 99234-99236].
Discharge to home. If the patient is only under the care of an emergency room physician, and is eventually discharged home, report this work with outpatient consult codes [99241-99245].
If the patient is critically ill during the initial consult visit and >30 minutes of critical care is provided by the consultant, only critical care [99291, 99292] and no other consult code set would be reported for that day. In the event that a consult is completed and at a later time on that calendar date, the consultant provides >30 minutes of critical care to the patient, both the consult and critical care service can be paid. The consult work would be reported using the rules above to select the appropriate code set.
Although previous guidance from Medicare has stated that a consult cannot be provided as a split/shared service, those rules only applied to consults reported with CPT codes 99241-99255. With Medicare consults now reported using different code sets, the rules for split/shared visits for Medicare patients now default to the rules for whichever set of codes are being reported for the consult. Thus, for inpatient consults reported with initial inpatient visit codes [99221-99223], these services can be provided and billed as split/shared visits. Check with individual nonmedicare payors for their rules regarding this situation.
The terms “comanagement” and “concurrent care” are often used interchangeably. Concurrent care is the situation when two physicians are managing different aspects of the patient’s care on the same calendar date on a more extensive basis than a one-time consultation, usually discussed in reference to two physicians submitting claims for inpatient follow-up services [99231-99233]. Two initial inpatient services [99221-99223] submitted on the same calendar date will be interpreted as consultation care and not fall under this discussion. The Medicare manual clearly states that the work of both physicians is reimbursable as long as the documentation reflects the medical necessity for each physician to provide their service. Although the two physicians are usually from different subspecialties, in the event that both are from the same specialty but one has documented expertise above and beyond the other, both services may be paid. An example of this could be an internal medicine hospitalist who is managing a patient with a COPD exacerbation, but elicits the help of another internal medicine hospitalist with expertise in pain management, to take over the daily care of the patient’s severe refractory chest pain from lung cancer. The medical necessity of each physician’s care should not only be reflected in the medical record, but also by each claim being submitted with different ICD-10 codes, showing the different aspects of care each provider is managing on that particular date. If both providers submit their service with the same primary ICD-10 code, only the first claim received by Medicare will be reimbursed. The second one will be denied.
Comanagement, defined by the Society of Hospital Medicine (SHM) and its Advisory Panel, is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” By convention, this term is used when a more formal arrangement is made between two physicians providing concurrent care. In the common situation involving a surgeon and medicine provider, the surgeon manages surgery related issues and the medicine hospitalist manages the patient’s medical conditions on an ongoing basis, often for the entire duration of the admission, and usually with the formal arrangement outlining each specialty’s responsibilities. From the start, the patient will be admitted to one service, with an order for the other subspecialty physician to see the patient. Just as in the example in the consult section above, the documentation must support the medical necessity for the second physician to be involved, not just for the initial visit, but also for each daily visit. Situations will arise where each physician in a comanagement arrangement may not need to see the patient every single day of the admission. No billing should be submitted for these days, even if the patient is physically seen by the physician, based on a mandated hospital protocol. Without documented medical necessity, this work is not reimbursable.
Several E/M services can be billed based on time (Table 28-1), with different billing nuances for each code set. In certain situations, the rules allowing reimbursement for these services differ between the CPT and Medicare manuals. When billing based on time, the only time that can be counted toward reimbursement of a service, is the billing provider’s time, not time spent on patient care by the resident, student, social worker, or nursing staff. For hospital based services, in addition to face-to-face time, the majority of E/M services also allow inclusion of time spent by the provider on the patient’s floor or in their unit (“unit/floor time”) providing patient care, toward billable time. In general, time is added up from 12:01 am to 11:59 pm, not over a 24-hour period, and does not need to be continuous. One exception to this is in the event that a time-based service is started before midnight, continuously provided, but not completed until after midnight. The CPT handbook advises if this should occur, to add up time that the service was provided continuously, and to bill for it on the date the service began.
COUNSELING AND COORDINATION OF CARE
When counseling and/or coordinating care (CCC) is the dominant feature of certain E/M visits, that is, when more than 50% of the total visit time (face to face and/or unit/floor), is spent counseling the patient and or coordinating their care, the level of service provided may be determined by the total visit time rather than by quantification of the documented history, physical, and medical decision making (MDM). The typical total visit times associated with these services are shown below.
TABLE 28-1Average Visit Times for E/M Services Billed as Counseling/Coordination Services and Threshold Times for Prolonged Services ||Download (.pdf) TABLE 28-1 Average Visit Times for E/M Services Billed as Counseling/Coordination Services and Threshold Times for Prolonged Services
|Medicare allows billing for counseling/coordination time and prolonged service only for services in bold below. The CPT manual allows both for all services in the table. |
|CPT Code ||Threshold to Visit Type ||Level ||Visit Time ||(Minutes) Average Bill 99356 ||Threshold to Bill 99357 |
|99218 ||105 ||Initial observation ||(1) ||30 ||60 |
|99219 || ||(2) ||50 ||80 ||125 |
|99220 || ||(3) ||70 ||100 ||145 |
|99221 ||Initial inpatient ||(1) ||30 ||60 ||105 |
|99222 || ||(2) ||50 ||80 ||125 |
|99223 || ||(3) ||70 ||100 ||145 |
|99224 ||Observation follow-up ||(1) ||15 ||45 ||90 |
|99225 || ||(2) ||25 ||55 ||100 |
|99226 || ||(3) ||35 ||65 ||110 |
|99231 ||Inpatient follow-up ||(1) ||15 ||45 ||90 |
|99232 || ||(2) ||25 ||55 ||100 |
|99233 || ||(3) ||35 ||65 ||110 |
|99234 ||Observation same day discharge ||(1) ||40 ||70 ||115 |
|99235 || ||(2) ||50 ||80 ||125 |
|99236 || ||(3) ||55 ||85 ||130 |
|99251 ||Inpatient consult ||(1) ||20 ||50 ||95 |
|99252 || ||(2) ||40 ||70 ||115 |
|99253 || ||(3) ||55 ||85 ||130 |
|99254 || ||(4) ||80 ||110 ||155 |
|99255 || ||(5) ||110 ||140 ||185 |
|99304 ||Initial SNF ||(1) ||25 ||55 ||100 |
|99305 || ||(2) ||35 ||65 ||110 |
|99306 || ||(3) ||45 ||75 ||120 |
|99307 ||SNF follow-up ||(1) ||10 ||40 ||85 |
|99308 || ||(2) ||15 ||45 ||90 |
|99309 || ||(3) ||25 ||55 ||100 |
|99310 || ||(4) ||35 ||65 ||110 |
|99318 ||Annual NF assessment || ||30 ||60 ||105 |
| || || ||(Minutes) |
|CPT Code ||Visit Type ||Level ||Average Visit Time ||Threshold to Bill 99354 ||Threshold to Bill 99355 |
|99201 ||New outpatient ||(1) ||10 ||40 ||85 |
|99202 || ||(2) ||20 ||50 ||95 |
|99203 || ||(3) ||30 ||60 ||105 |
|99204 || ||(4) ||45 ||75 ||120 |
|99205 || ||(5) ||60 ||90 ||135 |
|99212 ||Established outpatient ||(2) ||10 ||40 ||85 |
|99213 || ||(3) ||15 ||45 ||90 |
|99214 || ||(4) ||25 ||55 ||100 |
|99215 || ||(5) ||40 ||70 ||115 |
|99241 ||Outpatient consult ||(1) ||10 ||40 ||85 |
|99242 || ||(2) ||20 ||50 ||95 |
|99243 || ||(3) ||30 ||60 ||105 |
|99244 || ||(4) ||45 ||75 ||120 |
|99245 || ||(5) ||60 ||90 ||135 |
For example, if a patient is seen for inpatient follow up of a pulmonary embolism (PE) and a compliant level 2  visit is documented based on history, physical, and MDM, but it is also documented that >50% of a 35-minute face-to-face visit is spent counseling the patient on risk factors for a PE, evaluation, and treatment, time is now the controlling factor and a level 3  visit can be billed even though the history, physical, and MDM only amount to a level 2. Medicare will only allow time-based billing for CCC for inpatient admissions and follow-ups [99221-99233], SNF admissions and follow-ups [99304-99318], new outpatient visits [99201-99205], established outpatient visits [99212-99215], and other home services [99324-99350]. Medicaid and other insurers who follow the CPT handbook may also allow time-based billing for CCC for observation services [99218-99236] and consults [99241-99255] as well.
The Medicare Claims Processing Manual Chapter 12 states that the amount of CCC time may be estimated. In addition, the CPT manual instructs the provider to round the total visit time to the closest “average” total visit time. Thus in the example above, if 32 minutes were spent with the patient, 32 is closer to 35 minutes (average visit time for a level 3 follow-up ) than it is to 25 minutes (average visit time for a level 2 follow-up [ 99232]), and a level 3 service would be billed. This differs from the rules governing prolonged service total time determination below.
Tasks that count toward counseling the patient include but are not limited to discussions of the plan, evaluation, procedures, prognosis, treatment options, risk factor reduction, and patient and family education.
In order to bill for these services, two different amounts of time must be documented: the total visit time, and the portion of that total visit time that was spent CCC. Check with insurers and local compliance offices to see if the term “>50% of the total visit time was spent counseling the patient” is acceptable or if the specific number of minutes spent CCC needs to be explicitly documented. Neither the Medicare manual nor the CPT handbook list this as a documentation requirement. The most common documentation pitfall in successfully getting reimbursed for CCC time, is reporting only one time amount, thus making it impossible to determine that >50% of the total visit time was spent CCC. In addition, lack of a brief description of what was discussed during that time will cause a denial; the medical necessity for investing that time into the visit may not be obvious.
Examples of minimally acceptable reporting of time for billing the visit based on CCC:
I spent 20 minutes out of a 25-minute visit face-to-face and unit/floor time, counseling the patient on the safe use of home oxygen, and coordinating care with social work, setting up home oxygen, home nursing, and pulmonary rehab (level 2 inpatient follow-up visit ).
I spent 35 minutes face to face with the patient today. Twenty-five of those minutes were spent counseling the patient on her new diagnosis of breast cancer, the next steps in work-up, and possible treatment options including chemotherapy and XRT (level 3 inpatient follow-up visit ).
I spent 75 minutes with Mr X face-to-face and unit/floor time. More than fifty percent of that time was spent counseling the patient. The patient has very low health literacy and needed extensive counseling regarding acute renal failure, necessary inpatient work-up, and possible need for dialysis (level 3 inpatient admission ).
I spent 40 minutes face to face with the patient. One hundred percent of the time was spent counseling the patient on hospice and the grave prognosis for his metastatic lung cancer (level 3 inpatient follow-up visit ).
Examples of unacceptable reporting of CCC time for billing:
I spent 25 minutes counseling the patient on new diagnosis of lung cancer.
I spent 15 minutes face to face with the patient discussing the hospital course for his pneumonia.
I spent 10 minutes out of a 30-minute visit counseling the patient on what CHF is, low salt diet, and decreased fluid intake (10 minutes is less than 50% of the total visit time). This visit cannot be billed based on time; the documentation of history, physical, and MDM would be used to determine the level of service. Specifically, even though 10 minutes is >50% of a level 1 inpatient follow-up average visit time (15 minutes), this statement cannot be used in lieu of documenting the history, physical, and MDM to bill for the service.
I spent today’s entire visit counseling the patient on the differential diagnosis of his diarrhea and the planned work-up. (An auditor cannot try to determine how much time you spent with the patient based on the time orders were written, or the note was entered in the EMR. This service cannot be billed based on time.)
Prolonged service codes [99354-99359] are add on codes used when more than 30 minutes of care is provided beyond the typical or average visit time for the E/M service. They can never be billed alone, without their companion code—the primary E/M service. Time can be added up over the course of the calendar date not only by the provider, but also by their covering partners, including involvement by a nocturnist; the time each provider spent over the calendar date can be aggregated to determine to level of service provided. In this situation, the prolonged service would be reported under the NPI of the provider who is billing for the primary E/M service. Relative value units (RVUs) between the two providers would need to be adjusted internally for productivity purposes. Both physicians and nonphysician providers (NPPs) can bill for prolonged services. Finally, prolonged services may be provided and billed for as a split/shared visit. No restrictions are identified in either the CPT or Medicare manuals on how much time the physician must spend on the service relative to the NPP, in order to bill a split/shared visit. The documentation must clearly reflect that each provider performed a substantive portion of the service.
There are several differences between Medicare and CPT manuals’ rules governing how and when prolonged services may be provided and how they must be documented. Medicare only allows prolonged services to be billed when the primary E/M visit is an inpatient admission or follow-up [99221-99233], SNF admission or follow-up [99304-99318], new outpatient visit [99201-99205], established outpatient visit [99212-99215], or home or domiciliary visit [99324-99350]. Medicare does not allow prolonged services to be billed with observation admissions and follow-ups [99218-99236], however, the CPT manual does allow prolonged service billing with these observation services as well as with the consults codes [99241-99255]. For all payors including Medicare, prolonged services can never be billed with discharge management services [99238-99239, 99217], critical care [99291-99292], or procedures. In general, the direct patient contact services 99356-99357 are added on to inpatient and observation services, and 99354-99355 are added on to outpatient services (Table 28-1). 99358-99359 are prolonged services without direct patient contact, that is, without a face to face, and are not reimbursed by Medicare. These codes are usually used when extensive time is spent in chart review. Payment for these services varies among private insurers.
99354, 99356, and 99358 are billed for the “first hour” of prolonged service provided. These services can be billed once 30 minutes of prolonged service has been provided; the rules governing prolonged service care allow for each unit of service to be billed once 50% of the service time in the description has been met. 99355, 99357, and 99359 are billed for each additional “half hour” of prolonged service after the first hour of prolonged care. These services cannot be billed unless 99354, 99356, or 99358 has already been billed with the primary E/M. Again, once half of the time in the description is met, that is, 15 minutes, these services can be billed. Thus, in the inpatient setting, if 105 minutes of prolonged service has been provided beyond the typical visit time for the primary E/M visit, the first hour of prolonged care may be billed, PLUS the next half hour of care, PLUS another half hour of care. In addition to the primary E/M service, 99356 and 99357 × 2 would be submitted in this example. No modifiers are needed for billing these services. Medicare requires the service to “meet or exceed” the threshold time to allow reimbursement for prolonged services (Table 28-1). Note that this is different from the instruction to “round” to the nearest average visit time when billing for CCC. Thus if a level 2 inpatient visit is performed (typical visit time 25 minutes) and 52 minutes of face-to-face care was provided, the 55-minute threshold needed to bill for the first hour of prolonged service  has not been met, and the additional 27 minutes of care provided in this example is not reimbursable; only the level 2 inpatient follow-up  would be submitted for this care. Table 28-2 shows the cut off times needed to bill each unit of prolonged service.
TABLE 28-2Prolonged Service Billing ||Download (.pdf) TABLE 28-2 Prolonged Service Billing
|Minutes of Prolonged Service ||Outpatient ||CPT Codes Submitted Inpatient and Observation ||No Direct Patient Care |
|0-29 ||Only primary E/M ||Only primary E/M ||Only primary E/M |
|30-74 ||99354 ||99356 ||99358 |
|75-104 ||99354 + 99355 ||99356 + 99357 ||99358 + 99359 |
|105-134 ||99354 + 99355 × 2 ||99356 + 99357 × 2 ||99358 + 99359 × 2 |
|135-164 ||99354 + 99355 × 3 ||99356 + 99357 × 3 ||99358 + 99359 × 3 |
|165-194 ||99354 + 99355 × 4 ||99356 + 99357 × 4 ||99358 + 99359 × 4 |
|195+ ||- - - - - - - - - - - - - - - - - - - follow the pattern above - - - - - - - - - - - - - - - - - - - |
The rest of the discussion will focus only on services with direct patient contact [99354-99357]. Medicare only allows face-to-face time with the patient to be counted toward prolonged service billing, both in the outpatient as well as the inpatient setting [99354-99357]. Notice that this is different from Medicare’s rules for CCC, discharge management services, and critical care which all allow unit/floor time to be included as well. The CPT manual defines “direct patient contact” to mean only face-to-face time in the outpatient setting [99354-99355] but also time spent on the patient’s floor or in their unit for inpatient services [99356-99357]. This has a large impact on how prolonged services may be billed.
Prolonged services may be provided in addition to any level of service within the code sets above as long as >50% of the prolonged service time was not spent counseling the patient or coordinating their care. In the situation where CCC is the key feature of the visit, the highest level of service in the E/M code set must be used as the primary E/M before determining if any prolonged service time is billable. If less than 30 minutes of prolonged services are provided, that work is not separately reimbursable.
Example 1: A patient is seen with a new diagnosis of colon cancer and a fully compliant level 2 inpatient follow-up visit  is documented, based on history, physical, and MDM. Seventy-five minutes of face-to-face plus unit/floor time care (total visit time) is provided to the patient. Only 60 minutes of that time was face-to-face time, and >50% of the total visit time was spent counseling the patient regarding the new diagnosis, further necessary testing, treatment options, and plans for consultants. Although only a level 2 visit is documented, since CCC is the key feature of the service, the visit can be billed based on time. The highest level of inpatient follow-up service is a level 3  which is associated with an average visit time of 35 minutes. In Medicare patients, only face-to-face time can be used when determining if prolonged service time is separately reimbursable. Only 60 minutes of the total visit time was face to face. This means that 25 minutes of prolonged service care was provided (60 minutes total face-to-face time minus 35 minutes typical visit time for a level 3 follow-up). In this scenario, those 25 minutes are not separately reimbursable. This service for a Medicare patient would be reported as a level 3 inpatient follow-up .
Reimbursement would be different if this patient does not have Medicare, and the insurer follows the CPT manual. The total visit time would now be 75 minutes, adding in time spent providing care on the patient’s floor or in their unit. Now in addition to the level 3 inpatient follow-up visit, there are 40 minutes of prolonged service (75 minutes direct patient care time minus 35 minutes typical visit time for a level 3 inpatient follow-up). This service would now be reported as a level 3 inpatient follow-up  PLUS the first hour of prolonged service  which would result on average in ~$95 additional income.
Example 2: A non-English-speaking patient with an asthma exacerbation and lots of anxiety continues to call nursing several times during the day with shortness of breath, requiring repeated history taking, physical exam, and reassessment after each albuterol nebulizer treatment. In addition, each interaction with the patient requires the assistance of an interpreter. A compliant level 2 inpatient follow-up visit  is documented. Sixty minutes of face-to-face care is provided intermittently over the course of the day. The typical visit time for 99232 is 25 minutes. Thirty-five minutes of prolonged service that is not dominated by counseling or coordination of care is best reflected by 99232 PLUS 99356.
For Medicare, start and stop times for prolonged services and the indication for the prolonged time need to be documented along with a brief summary of what was done during that time in addition to the total face-to-face time providing care on that calendar date. The CPT handbook does not include a requirement for documenting start and stop times to bill for this service. There may be variable requirements among state Medicaid and private payors.
Critical care is defined in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12, as a physician’s direct delivery of medical care of a high-complexity MDM, to a critically ill or injured patient to prevent or stop imminent or active acute organ failure. A critical illness or injury acutely impairs one or more vital organ systems so that there is high probability of imminent or life threatening deterioration in the patient’s condition. Some examples of critical illness from the Medicare manual include circulatory failure, shock; renal, hepatic, or respiratory failure. Chronic organ failure management does not meet criteria for critical care services. Examples of this include chronic vent management and routine hemodialysis.
For a service to qualify as critical care, all four criteria must be met and adequately documented:
The medical necessity refers to a statement about the patient’s illness. The Medicare manual states “…The failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition….”
The service meets criteria for high-complexity medical decision making, and the high-complexity MDM is adequately documented in the chart.
The care is directly furnished by the physician, not by the resident, and not by a NPP in a split/shared situation. Critical care cannot be performed and billed as a split/shared visit.
The patient has a critical condition as defined above. Since critical care encompasses not only the “treatment of organ failure” but also the “prevention of further deterioration in the patient’s condition,” it is not a requirement that the person have an emergency or crisis situation to bill for critical care. The physician’s documented clinical judgment that the patient is at high risk of impending organ failure, or further deterioration in clinical condition, will support this criteria.
Seeing a critically ill patient does not automatically allow critical care billing. For example, an ophthalmologist seeing a septic patient on pressors, for glaucoma treatment, cannot bill for critical care.
There is no restriction to where critical care can be provided. It is not uncommon to provide critical care to a patient in a regular medical ward with an acute change in clinical status, while awaiting transfer to an intensive care unit. A patient is in the intensive care unit does not automatically allow for a critical care service to be billed. For example, a patient admitted to the ICU for acute respiratory failure 7 days ago, unable to wean off the ventilator, but stable for 3 days on their current vent settings, awaiting tracheostomy, no longer meets critical illness criteria. Neither does a patient who is in the ICU due to increased nursing needs such as a patient in diabetic ketoacidosis who needs glucose finger checks every hour, and the high nurse to patient ratio on the general ward, makes this level of care impossible or unsafe. Critical care billing is not warranted on a patient in an ICU bed only because the hospital policy requires it for their treatment, such as an insulin drip.
Critical care is a time-based service that follows the general rules of time-based coding. Both face-to-face and unit/floor time can be counted toward billable critical care time as long as the physician is in close proximity to the patient to immediately intervene for the minutes of reported critical care. If the physician is reviewing lab data on the patient’s floor but the patient is on a different floor getting a test done, in this scenario, the unit/floor time cannot be counted toward critical care time. For time reported as critical care time, the physician must provide their entire attention to management of the critically ill patient. For example, if the physician is at the critically ill patient’s bedside while an ECG is being performed, and while waiting, he is multitasking and looking up labs on another patient, this time cannot be counted toward critical care time. A minimum of 30 minutes of critical care must be provided to bill for critical care services. Twenty nine minutes or less of critical care would be billed with an E/M code that best reflects the service provided, such as an admission code [99221-99223] or inpatient follow-up code [99231-99233]. Once 30 minutes of critical care is provided, the first hour of critical care  can be billed. Each additional half hour of critical care  can be billed for thereafter (Table 28-3).
TABLE 28-3Critical Care Billing ||Download (.pdf) TABLE 28-3 Critical Care Billing
|Minutes of Critical Care ||CPT Codes Submitted |
|0-29 ||Submit appropriate E/M |
|30-74 ||99291 |
|75-104 ||99291 + 99292 |
|105-134 ||99291 + 99292 × 2 |
|135-164 ||99291 + 99292 × 3 |
|165-194 ||99291 + 99292 × 4 |
|195+ ||- - - - follow the pattern above - - - - |
In addition to time spent face to face with the patient taking a history and performing a physical exam, other activities that count toward critical care time include the following:
Time spent reviewing test results while on the patient’s floor or in their unit, and does not fall into the pitfall situation above. Time spent personally viewing a chest x-ray in the radiology suite on a different floor or looking at a peripheral smear in the hematology lab cannot be counted toward critical care time.
Time spent discussing the care plan with nursing staff or other consultants.
Discussions with family members or surrogates when both of these criteria are met (a) the patient lacks capacity or unable to participate in their own care and (b) the discussion directly impacts decision making. These discussions will count toward critical care time even if they occur via phone on the patient’s floor or in their unit. However, time spent on routine updates to family cannot be counted toward critical care services, and is not separately reimbursable.
Time spent performing procedures that are bundled into critical care (Table 28-4).
TABLE 28-4Procedures Bundled into Critical Care ||Download (.pdf) TABLE 28-4 Procedures Bundled into Critical Care
|Procedure ||CPT |
|IV placement ||36000 |
|Arterial blood gas ||36600 |
|Blood draws, physician skill needed ||36410, 36415, 36591 |
|NG tube placement (+fluoro, +lavage) ||43752, 91105 |
|Chest x-ray, professional component ||71010-26, 71015-26, 71020-26 |
|Temporary transcutaneous pacing ||92953 |
|Interpretation of cardiac output indices ||93561, 93562 |
|Ventilator management ||94002-94004, 94660, 94662 |
|Pulse-oximetry ||94760, 94761, 94762 |
|Data analysis from a computer ||99090 |
Activities that cannot count toward billable critical care time include work that does not directly contribute to the patient’s care, even if performed at the patient’s bedside:
Time looking up literature
Family updates, even if at the request of the patient
Time performing separately reimbursed procedures
Certain procedures when performed on the same date as a critical care service and by the same provider, are bundled into the reimbursement for critical care and cannot be billed for separately. (Table 28-4). Any medically necessary procedure not included in this table can be billed separately from critical care, such as central line placement, cardiopulmonary resuscitation, and intubation to name a few. The documentation should clearly state that the time performing these unbundled procedures is not included in the reported critical care time.
When critical care is provided by the same physician/billing group on the same date that another E/M service such as an inpatient admission, follow-up, or consult was provided earlier in the day when the patient was not critically ill, both the earlier E/M and the critical care service can be reimbursed. The exception to this rule is when the other E/M service is an emergency room visit [99281-99285]. An emergency room service cannot be paid on the same date as a critical care service by the same physician/billing group.
In a coverage situation, such as a change in shifts where a partner in the same billing group continues to provide critical care on the same calendar date, critical care time can be aggregated as long as the initial physician provided at least 30 minutes of critical care. For example, if Dr A provides 40 minutes of critical care at 6 pm and then Dr B takes over and provides an additional 35 minutes of critical care at 7 pm, the critical care time can be aggregated. A total of 75 minutes of critical care was provided; the first hour of critical care  would be submitted by Dr A and an additional half hour of critical care  would be submitted by Dr B. However, if Dr A had only provided 25 minutes of critical care and Dr B provided 50 minutes, although they still provided a total of 75 minutes of critical care, Dr A did not provide at least 30 minutes before going off shift. They cannot aggregate their critical care time. Dr A would bill an appropriate E/M code that best represents their work such as an inpatient admission or follow-up, and Dr B would bill for the first hour of critical care .
Two different physicians from different specialties can both receive payment for critical care services on the same calendar date if there is medical necessity for each of them to provide this level of care; however, two physicians cannot get paid for the same exact same minutes of critical care. For example, if Dr A, an internal medicine hospitalist, provides 30 minutes of critical care from 9 to 10 am stabilizing a patient with impending respiratory failure, and Dr B, the intensive care physician, provides critical care between 10 and 11 am, each physician would submit a claim for the first hour of critical care . In the event that both physicians provide care at the same time, only one physician will get paid for critical care. The other physician should submit an E/M code that best represents their work.
Having different subspecialty designations does not automatically allow each physician to submit a claim for the first hour of critical care. In the event that a member cross covering a patient happens to have a different subspecialty designation, but their role is to continue the care started by the previous physician, the work of the two physicians would be aggregated. For example, in a hospital medicine group, if Dr A is an internist and provides critical care for 30 minutes and then their partner Dr B, a cardiologist, comes on to cover the night shift and provides an additional 30 minutes of critical care, even if the patient’s critical illness happened to be a cardiac problem, in this situation, the two physicians would aggregate their work. A total of 60 minutes of critical care was provided, which is only enough to bill for the first hour of critical care. Only 99291 can be submitted in this scenario.
When providing critical care in tandem with a resident, the only time that the physician can count toward critical care billing, is the time they personally provide critical care, or time they are physically present while the resident provides critical care. For documentation, the resident’s note can help support the high complexity of MDM. In addition to meeting all teaching physician (TP) presence and documentation criteria, and writing a valid attestation statement linking the TP’s note to the resident’s note, the TP must personally document the following to bill for critical care.
The patient was critically ill at the time the TP was physically present and provided the service.
What the critical illness is. ICD-10 codes for a critical illness must be used, or the claim will be at high risk of initial denial.
The nature of the treatment and management they personally provided.
The number of minutes of critical care that they personally provided.
Documentation of the above by the resident is insufficient for billing. An example from the Medicare manual of minimally acceptable TP documentation for critical care: “Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care.”
DISCHARGE MANAGEMENT SERVICES
Discharge management services can only be billed by the primary attending of record, or a partner covering that day. All other consultants should bill an inpatient follow-up visit [99231-99233] or an established outpatient visit [99212-99215] based on the patient’s inpatient versus observation status as well as payor rules for observation services. For inpatient discharge management, there are two levels of service: <30 minutes  or >30 minutes . Both face-to-face and unit/floor time spent in discharge activities count, including but not limited to taking a history, the final physical exam, counseling the patient and family, reviewing data, writing prescriptions, and ordering follow-up appointments.
The only required documentation to bill for discharge management services is a statement attesting to having a face-to-face visit with the patient on the date of discharge management services. For legal, ethical, and high-quality patient care reasons, further documentation of the details of that visit would be prudent. When providing the higher level of inpatient discharge management , documentation must explicitly state how much time was spent on discharge management as well as a brief summary of what was done during that time. Lack of this statement will prevent reimbursement for the higher level of care . No time amount needs to be documented when billing the lower level of care . If extensive amounts of time over 30 minutes are spent on discharge management, there is no additional reimbursement for this care. Prolonged services cannot be billed with any discharge management code. There is only one level of discharge management for observation services regardless of the amount of time spent on care.
One of the most common documentation errors preventing reimbursement for the higher level of inpatient discharge is the statement “I spent 30 minutes on discharge management.” As opposed to other time-based services where 30 minutes is the minimum amount needed to bill a unit of service (ie, prolonged service, critical care), more than 30 minutes must be spent in discharge management to allow reimbursement for the 99239. This author suggests documenting the actual amount of time spent, in minutes.
Although palliative care has had its own subspecialty designation (17) since October 2009, many internal medicine hospitalists (subspecialty 11) have developed expertise in this field without formally changing their subspecialty designation from 11 to 17. When functioning as a consultant providing concurrent care to patients under the care of a colleague in the same subspecialty, there are several “best practices” to be aware of to minimize claims denials.
When providing concurrent care, one of the first pieces of evidence that medical necessity exists for two physicians to manage a patient on the same calendar date, is different subspecialty designations. A physician can go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) at any time and change their primary and secondary subspecialty designations. The physician should have evidence of expertise in their primary subspecialty designation; this does not have to be completion of an accredited fellowship program in that field. Recognition at the local, regional, or national level of expertise via activities such as publications, public speaking engagements, or development of institutional protocols or curricula, would satisfy this criteria. Documentation of constant and updated Continued Medical Education (CME) credit in that field would also count. Many physicians list their primary subspecialty designation as the field that they provide >50% of their services in. For internal medicine palliative care hospitalists, the percent of services provided as an internist may often outweigh that of their palliative care services; symptom-driven ICD-10 coding, complete descriptive documentation, and vigilant claims tracking are key to ensure appropriate reimbursement for these services.
SYMPTOM-DRIVEN ICD-10 CODING
Palliative care providers are often consulted to assist with maximizing quality of life and minimizing suffering for the time a patient has left. In doing so, the goals of care often center around symptom control and not disease management. This may differ from the primary attending’s care plan, which may employ palliative services, but which are still overall managing a disease state. Use of ICD-10 codes for symptoms being managed, not only better reflects the work of the palliative care provider, but also ensures that different ICD-10 codes will be submitted from the primary physician’s claim. For example, a patient with end-stage COPD is admitted for the eighth time this year with a COPD exacerbation, contemplating hospice care, and most bothered by dyspnea and fatigue. The palliative care provider’s documentation and plan will focus on control of the symptoms of dyspnea and fatigue, while the primary hospitalist’s note will focus on appropriate management of COPD. Claims for these services will be submitted with the ICD-10 codes for dyspnea [R06.0] and fatigue [R53.83], and COPD [J44.1] respectively.
COMPLETE AND DESCRIPTIVE DOCUMENTATION
Palliative care providers often spend enormous amounts of time counseling patients, and may bill a significant percent of their visits based on CCC. More detailed descriptions of the clinical situation will better support the medical necessity to spend these larger amounts of time with the patient. Adjectives may make a huge difference. A statement such as “patient extremely distraught over their terminal condition and required intense counseling regarding goals of end of life care” paints a much better picture for the need for 90 minutes of counseling than a statement like “Patient upset over terminal diagnosis. I counseled the patient on goals of care.”
TRACK CLAIMS AND CLAIM DENIALS
The best way to prevent future denials is to determine the reason for denial of a medically necessary visit, and use information learned from that encounter to prevent a denial for similar services. For example, a private insurer who sees two inpatient follow-up services [99231-99233] from the same subspecialty group on the same calendar date, even with different ICD-10’s, may deny it upfront simply because they require modifier –25 to be attached to one of the services. Another provider may require documentation to be submitted upfront for all situations where two inpatient follow-up visits are submitted on the same date. Lessons learned from these two denials alone may prevent hundreds more.
One way to help track these services internally would be to remember to submit ICD-10 code [Z51.5] for “encounter for palliative care services” with 100% of these services. This code should never be the primary diagnosis. Its use will not alter the amount of reimbursement for the visit; however its presence on a claim may alert an insurer that this service is separate and distinct from another E/M submitted by the same billing group, and prevent an upfront denial. At minimum, it will allow a physician to more easily search for these encounters in their data base to monitor payment for these services.
CPT 2015: Current Procedural Terminology. Cpt/Current Procedural Terminology Professional Edition. American Medical Association Press.
et al. Physician reimbursement for critical care services integrating palliative care for patients who are critically Ill. Chest