Evaluation and Management Help Center

Published 06/20/2022

The CY2022 CMS guidance regarding Split/Shared, Critical Care and other services is located in the following CMS publications:

Palmetto GBA is in the process of updating our web education related to these services based on the CMS guidelines and will notify our provider community through the jurisdictional websites and our Email Updates messaging. Please review the articles above for full details.

 

Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began.

Payment for a subsequent observation care code is for all the care rendered by the treating physician on the day(s) other than the initial or discharge date.

Observation Codes Scenarios
Reporting Requirements
Observation care for less than eight hours on the same calendar date
  • Report an initial observation, CPT code from code range 99218–99220
  • Observation care discharge service, CPT code 99217 cannot be reported
Admission for observation care followed by discharge on a different calendar date
  • Report an initial observation, CPT code from code range 99218–99220 along with
  • Observation care discharge service, CPT code 99217
Observation care continues for three days
  • Report an initial observation care CPT code from code range 99218–99220 for the first day of observation care;
  • Report a subsequent observation care CPT code from code range 99224–99226 for the second day of observation care; and
  • Report observation care discharge CPT code 99217 for observation care on the discharge date
Observation care continues beyond three days
  • Report a subsequent observation care CPT code (99224–99226) for each day between the first day of observation care and the discharge date
Observation care is received for a minimum eight hours, but less than 24 hours, and discharge occurs on the same calendar date
  • Report an observation or inpatient care services (including admission and discharge services) from CPT code range 99234–99236
  • Observation care discharge service, CPT code 99217 cannot be reported

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8 (PDF).

Last Reviewed: 6/20/2022

In the inpatient hospital setting, all physicians and qualified nonphysician practitioners (where permitted) who perform an initial evaluation visit may bill initial hospital care CPT® codes (99221–99223) or nursing facility care CPT codes (99304–99306).

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.1.G (PDF).

Last Reviewed: 6/20/2022

Yes, subsequent hospital CPT® codes (99232 and 99231) can be submitted in place of initial hospital CPT codes (99221–99223) if the minimum key component work and/or medical necessity requirements for initial care services are not met.

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claims Processing Manual, Chapter 12 (PDF), Section 30.6.9.1.F.

Last Reviewed: 6/20/2022

Yes. Hospital and nursing facility discharge services are time-based; codes are utilized to show the total duration of time that a physician or qualified health professional spent to discharge a patient. Time must be documented in the patient’s medical record to support the level of service billed.

Example
CPT code 99239 is billed. The patient’s discharge notes states "45 minutes of time spent performing discharge services." The documentation supports the provider billing CPT® code 99239 as more than 30 minutes of hospital discharge time is reported.

Hospital Discharge Codes

CPT Code
Code Description
99238
Hospital discharge day management, 30 minutes or less
99239
Hospital discharge day management, more than 30 minutes

Nursing Facility Discharge Codes

CPT Code
Code Description
99315
Nursing facility discharge management; 30 minutes or less
99316
Nursing facility discharge management; more than 30 minutes

Last Reviewed: 6/20/2022

Medicare pays for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8 (PDF).

Last Reviewed: 6/20/2022

If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether the patient should be admitted to the hospital or be sent home, the physician should bill as follows:

  • If the patient is admitted to the hospital by the patient’s personal physician, then the patient’s regular physician should bill only the appropriate level of the initial hospital care (codes 99221–99223) because all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes.
  • If the ED physician, based on the advice of the patient’s personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient’s personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. If the patient’s personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patient’s personal physician may not bill.

If the ED physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claim Processing Manual, Chapter 12, Section 30.6.11 E and F (PDF).

Last Reviewed: 6/20/2022

The use of VSS is not acceptable. The measurement of at least three of the seven vital signs must be documented.

  • Sitting or standing blood pressure
  • Supine blood pressure
  • Pulse rate and regularity
  • Respiration
  • Temperature
  • Height
  • Weight

Please keep in mind the elements under constitutional may be the general appearance of the patient and/or the measurement of any three of the seven vital signs listed above.

Resource: CMS MLN Evaluation and Management Services Guide.

Last Reviewed: 6/20/2022

It is not acceptable to document "noncontributory, unremarkable or negative." Because these statements do not indicate what was addressed.

If a physician is unable to obtain the history component from a patient or from another source, the patient’s medical record should reflect the reason why the patient's condition or other circumstance are preventing the medical professional from obtaining the patient’s history.

For example, the patient was adopted. No medical records obtainable from adoption agency or other medical facilities.

Resource: CMS MLN Evaluation and Management Services Guide.

Last Reviewed: 6/20/2022

In order for the service to be accurately scored, documentation must be legible to the clinician. In this case, you could submit a typed version of your notes for the visit. It would assist the reviewer in determining the specific services performed that day.

Resource: CMS 1995 & 1997 E/M Guidelines.

Last Reviewed: 6/20/2022

"New patient" means a patient who has not received any professional services, such as an E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a three year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed), then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test (reading an X-ray or EKG, etc.) in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Reference: CMS Internet-Only Manual (IOM) Medicare Claims Processing Manual, Chapter 12, Section 30.6.7 (PDF).

Last Reviewed: 6/20/2022

No. Pulse oximetry is not considered a vital sign. However, pulse oximetry is listed as a CPT 9xxxx series. If a physician reviews and/or orders a pulse oximetry, credit will be applied to the complexity of data portion of medical decision-making.

Resource: CMS MLN Evaluation and Management Services Guide.

Last Reviewed: 6/20/2022

The documentation must clearly reflect:

  • The components that were unobtainable (HPI, ROS and PFSH)
  • Circumstances that preclude obtaining the HPI, ROS and OFSH (dementia, sedated or a vent, etc.). When using "poor historian" the documentation must support why (e.g., dementia).
  • Attempt to obtain from other resources:
    • No family members were present to provide information
    • The medical record (chart, ambulance run sheet, etc.) did not contain the information needed
    • If patient or family can provide information later, the provider may add an addendum containing information

Resource: CMS MLN Evaluation and Management Services Guide.

Last Reviewed: 6/20/2022

Modifiers may be required to receive payment for some evaluation and management (E/M) services, if unbundling is not evident. Please review the CMS Global Surgery resource listed below and refer to the Modifier Lookup Tool that is located on Palmetto GBA’s website for further direction regarding your billed date of service.

Resource: CMS MLN Global Surgery Booklet.

Last Reviewed: 6/20/2022