After years of having to eat the cost of these services, you’re in the clear to bill
Myth: You can’t bill prolonged service codes for the lengthy E/M services that your physician performs in nursing facilities.
Reality: CMS now confirms that you can collect for those prolonged services when your physician spends additional time with a nursing facility patient.
History: When you want to report prolonged services, you look to CPT to determine the typical time that a service should take. Without that benchmark, you can’t know how much time a “prolonged” service should take.
But in 2006, CPT removed references to the typical time that practitioners should spend performing E/M services in nursing facilities, therefore no longer allowing these providers to report prolonged services or time-based counseling and coordination of care visits. CPT 2008 included new time guidelines that cover the codes in these categories, but CMS remained mum on whether Medicare would honor them, says Randall Karpf with East Billing.
CMS issued Transmittal 1489 on April 11 to clarify this issue, which states, “Medically necessary prolonged services for E/M visits [codes 99356 and 99357] in a SNF [skilled nursing facility] or NF [nursing facility] may be billed with the nursing facility services in the code ranges 99304-99310 and 99318.” You can use the typical times noted in CPT as a reference.
For example: The physician sees a patient for a visit that lasts 20 minutes. He decides that the patient needs an x-ray, so the patient leaves and returns that afternoon, whereupon the doctor reviews the x-ray with the patient and discusses treatment options. This second visit lasts 30 minutes.
Solution: “Since the patient left to have the x-ray done and then returned to discuss the results with the physician, 99354 would be appropriate” to report with the E/M service, says Wayne Mathis of Tennessee Sports Medicine and Orthopaedics. “This service is reported in addition to other physician services, including E/M services at any level. To bill for prolonged services, the physician has to spend at least 30 minutes with the patient, but it does not have to be continuous,” he says.
To read CMS Transmittal 1489, visit www.cms.hhs.gov/Transmittals/downloads/R1489CP.pdf.
Hint: Keep an eye on modifier choice
If you’ve been eating the cost of preoperative observation care, now’s your time to re-examine those charges.
You probably know that the global surgical fee includes hospital observation service payment -- but what you may not know is that you can report those observation services separately in some cases.
Although many other insurers have allowed you to bill certain observation services within the global period for years, CMS’s stance was vague. But that changes with the introduction of new Medicare guidance that can make the issue easier to understand.
According to recent CMS Transmittal 1466, you can report observation codes 99217-99220 and 99234-99236 along with the global surgical fee if you meet the following two criteria:
· You can justify billing the observation service with modifier 24 (Unrelated evaluation and management service during a postoperative period), 25 (Significant, separately identifiable evaluation and management service by the same physician) or 57 (Decision for surgery)
· The observation service meets all of the conditions for billing the observation code.
“What they’re saying is that you can’t bill for observation for anything surgery-related, but you can report the observation separately if the observation stay supports the use of a global-breaking modifier,” says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions.
Postop example: A patient undergoes abdominal surgery and is about to be discharged from the hospital when he begins to experience respiratory problems. The physician admits the patient to observation so the physician can evaluate the respiratory issue.
Solution: In this case, “you’d bill the observation care with modifier 24 appended because the observation care is unrelated to the surgery,” Cobuzzi says.
Preop example: A patient is admitted to observation care so the physician can observe his vertebral injury. During the observation period, the surgeon decides that the patient requires surgical intervention.
Solution: In this case, you should charge the observation code with modifier 57 appended, as well as the surgery, says Jacqui Jones, office manager for Benjamin F. Balme, MD, PC, in Klamath Falls, Ore.
Remember to check the hospital records to determine whether the patient was admitted to observation care, inpatient status, etc., “because it really matters if the physician billing differs from the hospital billing as far as place of service,” Jones says.
To read CMS Transmittal 1466, visit www.cms.hhs.gov/transmittals/downloads/R1466CP.pdf