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Evaluation and management (E/M) FAQs
Last Modified: 4/7/2024
Location: FL, PR, USVI
Business: Part A, Part B
1Q: Can the 1995 and 1997 guidelines be used for any E/M services provided on or after January 1, 2023?
1A: No, CMS adopted the revisions finalized by the American Medical Association (AMA) CPT Editorial Panel for calendar year 2023 which impacts multiple E/M visit code families. The AMA revisions were made to align the coding process and guidelines to match the general framework currently in place for office and outpatient E/M visits, which were redefined and put into effect on January 1, 2021:
2Q: Can the 1995 and 1997 guidelines be used when a visit is split (or shared) between a physician and non-physician practitioner for services performed on and after January 1, 2023?
2A: No. CMS adopted the revisions finalized by the American Medical Association (AMA) CPT Editorial Panel for calendar year 2023 which impacts multiple E/M visit code families. The AMA revisions were made to align the coding process and guidelines to match the general framework currently in place for office and outpatient E/M visits, which were redefined and put into effect on January 1, 2021:
3Q: Which E/M codes fall into the "other E/M" category addressed in the 2023 updates?
3A: These 2023 updates apply to inpatient and observation visits, emergency department visits, nursing facility visits, domiciliary or rest home visits, home visits and cognitive impairment assessment.
4Q: Does the substantive portion only apply to split (or shared) visits?
4A: Yes, the substantive portion determines which practitioner can bill the E/M visit when performed in the facility setting in part by both a physician and a nonphysician practitioner (NPP) who are in the same group practice. For Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making. Payment is made to the practitioner who performs the substantive portion of the visit. Modifier -FS must be reported on claims to identify the service was a split (or shared) visit.
5Q: How is the substantive portion determined when the level of service is based on time?
5A: For Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.
The practitioner who spends more than half of the total time described in the code descriptor can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit. Modifier -FS must be reported on claims to identify the service was a split (or shared) visit.
6Q: How is the substantive portion determined when the level of service is based on medical decision making?
6A: For Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.
Based on guidelines in effect for 2022 and 2023, when one of the three key components is used as the substantive portion, the practitioner who bills the visit must perform that component in its entirety in order to bill. For example, if history is used as the substantive portion, the billing practitioner must perform the history as described in the code descriptor in order to bill. If physical exam is used as the substantive portion, the billing practitioner must perform the exam as described in the code descriptor in order to bill. If MDM is used as the substantive portion, each practitioner could perform certain aspects of MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed. Modifier -FS must be reported on claims to identify the service was a split (or shared) visit.
7Q: The prolonged codes in the CPT manual are different than those in the CMS IOM - which do we follow?
7A: CMS has created Medicare-specific codes that must be used to report prolonged E/M services and E/M visit complexity add-on services.
8Q: Who bills the prolonged codes when the service is split (or shared) between two practitioners?
8A: The physician or practitioner who spent more than half the total time will bill for the primary E/M visit and the prolonged service code(s) when the service is furnished as a split (or shared) visit, if all other requirements to bill for split (or shared) services are met.
9Q: Where can the CPT E/M code and guideline changes for 2021 be found?
10Q: Where can the revised medical decision-making table for 2021 be found?
11Q: Where can the new CPT E/M definitions be found?
12Q: Do the 2021 E/M code and guideline changes apply to all categories of E/M services?
12A: No. The 2021 E/M code and guideline changes are specific for office and other outpatient visits and apply to codes 99201–99205 and 99211–99215.
Note: Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, 2021:
13Q: For dates of service on and after January 1, 2021, how are the levels of E/M services provided in an office/outpatient setting determined?
13A: Effective for dates of service on and after January 1, 2021, select the appropriate level of E/M service based on the following:
• The level of the medical decision making as defined for each service; OR
• The total time for the E/M service performed on the date of the encounter.
14Q: Can office visits be split (or shared) between a physician and non-physician practitioner?
14A: Office visits and nursing facility visits are not billable as split (or shared) services. Split (or shared) visits are furnished only in the facility setting, meaning institutional settings in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under CMS regulations at 42 CFR § 410.26Q:
15Q: Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines?
15A: The approved revisions did not materially change the three MDM elements, but instead provide extensive edits to the elements for code selection, and revised or created numerous clarifying definitions in the E/M guidelines.
The revised code descriptors state a "medically appropriate history and/or examination" is required.
16Q: How is time defined for office and outpatient E/M services for dates of service on and after January 1, 2021?
16A: For dates of service on and after January 1, 2021, time is defined as minimum time, not typical time, and represents the total physician or other qualified health care professional time on the date of service. The use of 'date-of-service time' builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services, like care coordination.
This definition applies only when code selection is based on time and not MDM.
17Q: When coding based on time, is the day of the encounter considered the actual calendar date or a 24-hour period?
18Q: How is time measured in the CPT E/M code and guideline changes for 2021?
18A: Except for code 99211, per AMA, beginning with CPT changes 2021, time alone may be used to select the appropriate code level for the office or other outpatient E/M service codes (99202-99205, 99212- 99215).
Time may be used to select a code level for office or other outpatient services whether or not counseling and/or coordination of care dominates the service.
When time is used to select the appropriate level for E/M service codes, time is defined by the service descriptors. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health professional.
For office or other outpatient services, if the physician’s or other qualified health professional's time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use code 99211:
19Q: What activities are included in physician's time?
19A: Physician/other qualified health care professional time includes the following activities when performed:
• Preparing to see the patient (e.g., review of tests).
• Obtaining and/or reviewing separately obtained history.
• Performing a medically appropriate examination and/or evaluation.
• Counseling and educating the patient/family/caregiver.
• Ordering medications, tests, or procedures.
• Referring and communicating with other health care professionals (when not separately reported).
• Documenting clinical information in the electronic or other health record.
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
• Care coordination (not separately reported).
20Q: Does First Coast have a worksheet based on the CPT E/M guideline changes for 2021?
20A: The interactive worksheet assists providers with identifying the appropriate E/M code based upon either the:
• 1995 or 1997 Documentation Guidelines for Evaluation and Management Services, or
• AMA CPT E/M Code Guideline Changes for 2021 (effective for office and outpatient visits for dates of service on and after January 1, 2021), or
• E/M Code and Guideline Changes for 2023 (effective for other E/M visits for dates of service on and after January 1, 2023).
Since the 1995 and 1997 guidelines or AMA CPT E/M Code and guideline changes for 2021 and 2023 each specify different criteria to determine the level of E/M service performed, only one set of guidelines may be used to document a specific patient visit. For other E/M visit dates of service prior to January 1, 2023, this interactive worksheet offers providers the option to select either their preferred set of guidelines (1995 or 1997) or to select both sets for the purpose of comparison.
21Q: Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?
21A: Per AMA, the ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation but may be counted as ordered or reviewed for selecting an MDM level. If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is part of MDM.
22Q: When auditing MDM, is there a list of drugs considered “drug therapy requiring intensive monitoring for toxicity?”
22A: CMS itself has not provided such a list for use with the 1995 or 1997 guidelines. This question is answered in the CPT changes for 2021:
“Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.”
Q: What are the guidelines for billing HCPCS code G2211?
A: The new evaluation and management (E/M) office and outpatient (O/O) add-on HCPCS code G2211 is used to represent visit complexity when reported with CPT codes 99202-99205 and 99211-99215. As noted in
MLN Matters Article MM13272: Edits to Prevent Payment of G2211 with Office and Outpatient Evaluation and Management Visit and Modifier 25 
, payment will be denied when reporting G2211 with O/O E/M CPT codes 99202-99205 and 99211-99215 with modifier 25. The provider should determine if they may report the O/O E/M codes with other services, such as an EKG, immunization, or allergy shot, or if a modifier, such as modifier 25, should be appended to the E/M service when reported during the same encounter.
For most E/M visit code families, practitioners will select a visit level based on the level of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner. For all E/M visits, practitioners should perform a history and physical exam in accordance with code descriptors, but history and exam no longer impact visit level selection. When time is used to select a level of service, the total visit time must be met or exceeded; the general CPT rule regarding the midpoint for certain timed services does not apply.
• Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code.
• It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted.
• The volume of documentation should not be the primary influence on the specific level of service billed.
• Documentation must support the level of service reported.
In situations where the O/O E/M visit is with a patient in a routine or time-limited nature, G2211 should not be reported, including:
• Mole removal
• Treatment of a simple virus
• Counseling of seasonal allergies
• When the physician has not taken responsibility for ongoing care with consistency and continuity over time
1Q: If a physician sees a patient in the office in the morning for a new condition and again in the afternoon because the condition has worsened, should modifier -25 be appended the afternoon visit?
1A: No. The physician would be expected to combine the documentation of both encounters and bill one E/M based on the combined documentation. Modifier -25 would not be appropriate for this scenario. Modifier -25 is used to identify a significantly, separately identifiable E/M service performed by a physician on the same date as a procedure or other service.
2Q: Is it possible for the same physician to bill and be paid for a second E/M service on the same date of service for the same patient?
2A: If a second E/M service is required on the same date of service, the documentation should clearly provide evidence of the second E/M service occurring, the reason for the additional E/M service, and documentation of the medical necessity of the second E/M service. When reporting a second E/M service on the same date, the service will initially deny as only one E/M is reimbursable per day, per patient, per physician or same group, same specialty. You may appeal the denial with documentation. First Coast would not expect to see two E/M services reported on the same date on a routine basis. Information on the appeals process is available at
How to appeal a claim.
3Q: How do you bill E/M services performed on the same day as other services?
3A: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service).
E/M services may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.
Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery; see modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
4Q: How does First Coast review an E/M billed with modifier -25?
4A: Modifier -25 is used to report significant and separately identifiable E/M services by the same physician on the same day of the procedure or other service. In the review of E/M services billed with the -25 modifier, we will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. We also consider the additional documentation for the additional service separate from the documentation specific to the initial procedure or service to determine:
• If there is a significant, separately identifiable E/M service that was rendered and documented, and
• If the required components of the E/M service are supported as "reasonable and necessary" per Social Security Act, Section 1862(a)(1)(A), and
• If the level of care is supported by the documentation contained in the medical records.
5Q: Can two physicians in the same group practice, who see the same patient on the same day, each bill for an E/M service and receive payment?
5A: Physicians in the same group practice but who are in different specialties may bill and be paid separately without regard to their membership in the same group.
Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
6Q: How is the -AI modifier used?
6A: The principal physician of record appends modifier “-AI” to their initial hospital care visit code. This modifier identifies the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient bill without the "-AI" to indicate specialty care.
This modifier is informational only. It does not affect reimbursement. Claims which include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.
7Q: Can modifier -25 be used on 99211?
7A: No, it is not appropriate to append modifier 25 to 99211Q: According to CMS, it is appropriate to append modifier -25 when the modifier indicates that a separately identifiable E/M service was performed that meets a higher complexity level of care than a service represented by 99211:
8Q: If a physician moves from one group practice to another, can the physician bill the patients as new if they go to the new practice?
8A: The provider would not be able to bill previously seen patients as a new patient unless he meets the three-year guideline for a new patient visit.
A new patient is defined as a patient who has not received any professional services, i.e., E/M services or other face-to-face services from the physician or physician group practice within the previous three years.
1Q: How is medical necessity considered when scoring medical records?
1A: All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, "…no payment may be made for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member." Therefore, medical necessity is the first consideration in reviewing all services.
2Q: Is it acceptable to use abbreviations in the patient’s medical record?
2A: Abbreviations may be used in the patient's medical record. If your patients' medical records contain abbreviations not commonly used, and you receive a request for medical records, please provide a key to the abbreviations. Submit the key with the medical records to assist us in the review.
Effective January 1, 2023, the AMA CPT Editorial Panel approved revised coding and updated guidelines for "Other E/M visits" (which includes hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessments). CMS is adopting most of the CPT’s revised guidance, including deletion of several CPT codes.
Effective for dates of service (DOS) on and after January 1, 2023, practitioners have the choice to document most E/M visits via medical decision making (MDM) or time, except emergency department visits and cognitive impairment assessments, which are not timed services.
The E/M code and guideline changes are like those already applied to office and other outpatient visits, which were effective for dates of service on and after January 1, 2021:
3Q: If the physician states same/unchanged from last visit, will he receive credit for reviewing the last visit information?
3A: Yes, only if the physician includes the documentation from the previous visit. Otherwise, the reviewer would not know what was the same or unchanged from the previous visit.
4Q: What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019?
4A: The CY 2019 PFS final rule expanded current policy for office/outpatient E/M visits starting January 1, 2019, to provide that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that she or she has done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (History of Present Illness (HPI), Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits. To clarify terminology, we are using the term “history” broadly in the same way that the 1995 and 1997 E/M documentation guidelines use this term in describing the CC, ROS and PFSH as “components of history that can be listed separately or included in the description of HPI.” This policy does not address (and we believe never has addressed) who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.
1Q: My patient visits are primarily counseling and coordination of care. How do I bill for this type of patient visit?
1A: For dates of service prior to January 1, 2021, for office and outpatient E/M codes and dates of service prior to January 1, 2023, for other E/M codes, when counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during an E/M service then time may be considered as the controlling factor to qualify the E/M service for a particular level of care. If the physician elects to report the level of care based on counseling and/or coordination of care, then several factors must be in the patient's medical record. The following must be in the patient's medical record in order to report an E/M service based on time:
• The total length of time of the E/M visit.
• Evidence that more than half of the total length of time of the E/M visit was spent in counseling and coordinating of care; and
• The content of the counseling and coordination of care provided during the E/M visit.
For dates of service on and/or after January 1, 2021, for office and outpatient E/M codes and dates of service on and/or after January 1, 2023, for other E/M codes, the level of E/M is based on the total time performed on the date of the encounter whether or not counseling or coordination of care dominates the service.
Medicare no longer recognizes consultation codes (99241-99245 and 99251-99255). Physicians shall code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed.
1Q: NPP sees patient at 9 a.m. and records 90 minutes of critical care, later a physician from the same group practice sees the same patient at 2 p.m. and records 25 minutes of critical care services. How is this billed?
1A: This is considered a split (or shared) visit. The time would be aggregated for a total of 115 minutes, 99291 and 99292 with modifier -FS is billable by the NPP since the NPP performed the substantive portion (more than half of the total time).
2Q: If a patient is seen by both the physician and NPP from the same group practice at the same time, can the time of both be counted for the total time?
2A: Although this would be considered a split (or shared) visit, the overlapping time can only be counted once.
3Q: Please define the time requirement for billing CPT code 99292Q:
3A: Whether critical care is performed by a single provider or on a split (or shared) basis, the time requirement for CPT code 99292 remains the same. 99292 requires a full 30 minutes of critical care after the base billing period of 74 minutes for 99291 has been reached. Therefore, 99292 is not reported until at least 104 minutes of critical care have been performed (74 + 30 = 104 minutes). Time for critical care on a single date of service may be continuous or cumulative among qualified providers in the same group.
4Q: When documenting the total time, is it required to document the actual minutes or a start and stop time?
4A: Critical care is a time-based service. The time documented in the medical record must reveal a total time using either minutes or start and stop times (preferred).
5Q: What is considered the substantive portion when billing critical care services?
5A: Critical care is a time-based service. The substantive portion for critical care services is defined as more than half of the total time spent by the physician or NPP beginning January 1, 2022:
6Q: Do you also use modifier 24 with FT when critical care is unrelated to the surgery during a global surgery?
6A: No, modifier FT would be used for critical visits that are unrelated to the surgical procedure but performed on the same day; or when critical care services provided during a global surgical period are unrelated to a surgical procedure.
7Q: Can a physician bill critical care services and a discharge service on the same day if the patient is transferred to another facility or expires?
7A: In situations when a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation notes that 1) the other E/M visit was provided before the critical care and at a time when the patient did not require critical care; 2) the services were medically necessary; and 3) the services were separate and distinct with no duplicative elements from the critical care services occurring later in the day. Additionally, the modifier -25 should be appended to the critical care services on the claim for this day.
8Q: May a surgeon bill for critical care service(s) in the global surgery period when care is unrelated to the surgery?
8A: Yes, critical care may be billed in this situation by adding modifier FT to the critical care service. Documentation must clearly support the reason for the service as unrelated to the primary surgical event.
9Q: What is the correct way to report critical care when the continuous critical care time crosses midnight into the next calendar date?
9A: When using MDM or time for code selection, a continuous service that spans the transition of 2 calendar dates is a single service and is reported on one date, which is the date the encounter begins. If the service is continuous, before and through midnight, all the time may be applied to the reported date of the service (that is, the calendar date the encounter began).
10Q: Where can more information be found regarding critical care services?
10A: First Coast published a
critical care article to summarize the CMS changes effective January 1, 2022:
1Q: When a patient presents to an emergency department prior to midnight and the physician sees them after midnight, which date of service do we report?
1A: The date of service would be the date the physician performs a face-to-face service with the patient. If the service started on one day and carried over continuously thru midnight into the next day, the date the service began is the date of service. If the physician did not see the patient until after midnight, the date of service is the date of the face-to-face encounter.
2Q: If a patient is seen in the emergency department, then admitted to the hospital, how should this be billed?
2A: The CMS IOM states A/B MACs (B) pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. Medicare does not pay for both an emergency department visit and a hospital admission on the same date of service by the same physician.
When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with the admission are considered part of the initial hospital care when performed on the same date as the admission.
1Q: Are written orders required by a physician or NPP for observation services?
1A: The order for observation must be in writing and clearly specify outpatient observation. It should also include the reason for observation and be signed, dated, and timed by the ordering physician.
2Q: When a patient is receiving outpatient observation services, who bills the hospital inpatient and observation care codes?
2A: The hospital inpatient and observation care codes are billed only by the physician who ordered the hospital outpatient observation services and was responsible for the patient during his/her observation care. All other practitioners bill office and outpatient codes.
3Q: What is billed if the patient is admitted to outpatient observation care and later, on the same day, admitted as a hospital inpatient by the same physician?
3A: A transition from outpatient observation care to inpatient status does not constitute a new stay. Initial and subsequent hospital or observation care codes may not be billed for observation services provided on the same date the physician admits the patient as an inpatient.
If the patient is admitted as an inpatient by the same physician, or physician of the same specialty in the same group practice, on the same day as the observation admission, bill only one initial hospital inpatient or observation care code 99221-99223 for the inpatient admission. Medicare payment for the hospital inpatient or observation care codes include all services provided to the patient by the same physician on the date of admission regardless of the site of service. The place of service code should identify the patient's location as inpatient (POS 21) for the service billed.
4Q: What is billed if the patient is admitted to outpatient observation care and admitted as a hospital inpatient by the same physician on the next day?
4A: If the patient is admitted by the same physician, or physician of the same specialty in the same group practice, as an inpatient on the next/subsequent day following an outpatient observation care day, bill a subsequent hospital inpatient or observation care code, 99231-99233 for the hospital admission. A transition from outpatient observation care to inpatient status does not constitute a new stay. The place of service code should identify the patient's location as inpatient (POS 21) for the service billed.
The physician may not bill a hospital inpatient or observation discharge management code or an outpatient/office visit for the care provided while the patient received hospital outpatient observation services on the date of admission to inpatient status.
5Q: Can outpatient observation care be split (or shared) between a physician and non-physician practitioner?
5A: Observation services may be split (or shared) between a physician and non-physician practitioner in the same group practice. One of the practitioners must have face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician, nor the practitioner who performs the substantive portion and bills for the visit. The substantive portion can be entirely with or without direct patient contact. For Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.
Modifier -FS must be reported on claims to identify the service was a split (or shared) visit.
6Q: How does Medicare determine the difference between outpatient observation care and inpatient hospital care when the CPT codes are now the same?
6A: Although the CPT codes for inpatient hospital and outpatient observation care are the same, the place of service code should identify the patient's location as inpatient (POS 21) or outpatient (POS 22).
7Q: Where can additional observation information be found?
1Q: Does Medicare allow payment for E/M visits in a patient's home?
1A: Starting with claims for services on January 1, 2023, the two E/M visit families titled “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” and “Home Services” are now one E/M code family. The new family is titled “Home or Residence Services.”
Use the codes in this family to report E/M services you provide to a patient in:
• Their home or residence
• An assisted living facility
• A group home (that isn’t licensed as an intermediate care facility for individuals with intellectual disabilities)
• A custodial care facility
• A residential substance abuse treatment facility
There are no changes to the included care settings from each respective family, rather the current care settings for each of the current families are in the new, merged family.
2Q. Which place of service codes are used for Home and Residence visits?
2A: In addition to POS 12 for the patient's home, Medicare will allow the following POS codes to accommodate the merger of Domiciliary visit codes with Home visit codes:
• POS 13 -- Assisted Living Facility
• POS 14 -- Group Home
• POS 33 -- Custodial Care Facility
• POS 55 -- Residential Substance Abuse Treatment Facility
3Q: If the physician is billing a home visit with codes 99341-99350, is their physical presence required?
3A: A home visit using codes 99341-99350 with POS 12 cannot be billed by a physician unless the physician was present in the beneficiary's home.
Patient visits conducted via telehealth would be billed as though the patient had appeared in the office (POS 11); Do NOT use home visit codes for telehealth services.
4Q: Can a podiatrist bill a home visit?
4A: Yes, as long as home visits are within the scope of practice and state licensure for podiatrists, and the service rendered is medically necessary.
5Q: Where can additional information for home visits be found.
Initial Hospital Inpatient or Observation Care 1Q: How does Medicare define an initial service?
1A: An initial service is one that occurs when the patient has not received any professional services from the physician or NPP or another physician or NPP of the same specialty who belongs to the same group practice during the stay.
2Q: Will Medicare make payment for more than one initial hospital visit during the same admission performed by providers of the same specialty but different group practices?
2A: No, Medicare does not reimburse multiple visits to providers of the same specialty within the same and/or different group practices. Medicare will reimburse multiple visits to physicians from different groups and different specialties, or physicians of different specialties within the same group practice.
3Q: Does Medicare allow an initial hospital care service on a day following an office visit?
3A: Medicare pays both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission.
4Q: If we decide to admit from the office, should we bill the office visit and the lowest initial admission code?
4A: No, if admitting the patient after an office visit, the initial hospital code would include all work performed by the physician in all sites. The initial hospital care day would be the only code reported if the physician performed a face-to-face visit in the hospital setting as well as the office.
5Q: Will Medicare pay for more than one initial hospital visit per hospital admission?
5A: In the inpatient hospital setting and nursing facility setting, any physician and/or qualified non-physician practitioner who performs an initial evaluation may bill an initial hospital care visit code (99221 – 99223) or nursing facility care visit code (99304 – 99306), where appropriate. Medicare will only pay for one initial hospital care day per patient, per admission, per specialty.
6Q: Am I permitted to bill an initial hospital visit (for a consultation) even though I have an established relationship with the patient?
6A: Yes. The concept of a new or established patient does not apply to inpatient hospital care days. Practitioners can use these codes for the first visit to an inpatient even if they have an established relationship with the patient.
7Q: Will Medicare allow an initial hospital inpatient visit and a discharge to be paid on the same day?
7A: For patients admitted to hospital inpatient care or observation care for less than eight hours on the same date, only the initial hospital or observation care (99221–99223) is reported by the provider. The hospital discharge day management service is not reportable.
For patients admitted as a hospital inpatient and discharged on a different calendar date, the physician bills initial inpatient hospital care using the initial inpatient hospital and observation care codes, 99221–99223 and the hospital discharge day management service using the hospital inpatient or observation discharge services, codes 99238 or 99239.
Patients admitted to inpatient hospital care for a minimum of eight hours but less than 24 hours and discharged on the same calendar date are billed using the hospital inpatient or observation care services (including admission and discharge services), codes 99234-99236.
8Q: One of the cardiologists from our group saw a patient in the hospital this morning. The patient worsened and needed to be seen later in the day. Can the first cardiologist bill an initial and the other cardiologist bill a subsequent visit.
8A: No. Medicare does not pay two E/M visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day. Physicians (same group/same specialty) must bill and be paid as a single physician. Select a level of service representative of the combined visits and submit the appropriate code.
9Q: Where can I find guidelines for initial hospital visits?
10Q: How does Medicare define a subsequent hospital visit?
10A: A subsequent hospital service is one that occurs when the patient has received any professional services from the physician or NPP or another physician or NPP of the same specialty who belongs to the same group practice during the stay.
11Q: Can two different providers bill a subsequent hospital visit on the same day?
11A: Subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.
If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.
1Q: Can any physician bill the hospital discharge day management service?
1A: Only the attending provider of record reports the discharge day management service.
2Q: How do I bill discharge day management when I discharged my patient on day one, but dictated my notes on day 2? Which day do I use for submitting the claim?
2A: Bill the discharge day management with the actual discharge date. The medical records should clearly state the date of the actual discharge and dictated the following date.
3Q: How are hospital discharge services reported?
3A: As the CPT manual explains, hospital discharge day management codes are to be utilized to report all services provided to a patient on the date of discharge, if other than the initial date of inpatient status:
• 99238 – Hospital discharge day management; 30 minutes or less
• 99239 – Hospital discharge day management; more than 30 minutes
To report services for a patient who is admitted inpatient and discharged on the same date, use codes 99234-99236 for observation or inpatient hospital care including admission and discharge of the patient on the same date. To report concurrent care services provided by an individual other than the practitioner performing the discharge day management service, use subsequent hospital care codes (99231-99233) on the day of discharge.
4Q: What date is used when reporting a hospital discharge day management service?
4A: A hospital discharge day management service (99238 or 99239) is a face-to-face E/M service between the attending provider and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner (NPP), even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient, per hospital stay.
Only the attending provider of record reports the discharge day management service.
Medicare pays for the paperwork of patient discharge day management through the pre-and post-service work of an E/M service.
5Q: Will Medicare pay for multiple hospital discharges on the same calendar day for the same patient?
5A: No, only one discharge is permitted per patient admission.
To report concurrent care services provided by an individual other than the practitioner performing the discharge day management service, use subsequent hospital care codes (99231-99233) on the day of discharge.
6Q: What if the attending provider of record is not available to discharge a patient but his partner from his same group is?
6A: Physicians of the same group with the same specialty are recognized as a single physician. It is acceptable for physicians of the same specialty from the same group practice to perform the discharge.
7Q: Who is paid for the hospital discharge management and death pronouncement?
7A: Only the physician who personally performs pronouncement of death shall bill for the face-to-face hospital discharge day management service (99238 or 99239). The date of the pronouncement shall reflect the calendar date on the day the service was performed, even if paperwork is delayed to a subsequent date.
8Q: How do you bill for a patient who expired?
8A: According to established legal principles, an individual is not deceased until there has been official pronouncement of death. Therefore, an individual expired at the time of pronouncement of death by a legally authorized person who is usually a physician. Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services.
9Q: Why are services for hospital discharge day management being reduced from 99239 to 99238?
9A: Services may be reduced when the medical records do not contain the time the physician spent with the patient. Hospital discharge day management codes 99238 (30 minutes or less) and 99239 (more than 30 minutes) are time based so it is imperative that medical documentation reflect total time spent by a physician during the discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, (even if the time spent by the physician on that date is not continuous), instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions, and referral forms.
10Q: If my patient is admitted at 11 p.m. and discharged at 9 a.m. the next morning, can I bill the admission and discharge codes 99234-99236?
10A: Admission and discharge codes (99234-99236) are only billable when admission and discharge occur on the same calendar day and include more than 8 hours but less than 24 hours. Each calendar day is billable as long as a face-to-face visit is done on both.
If the service is continuous service, before and through midnight and spans the transition of 2 calendar dates, only a single service is reported on the date the encounter begins. If the service is continuous, all the time may be applied to the reported date of the service (that is, the calendar date the encounter began).
11Q: Does Medicare allow a hospital discharge management and nursing facility admission to be paid when rendered on same day?
11A: When a patient is discharged from a hospital and admitted to a nursing facility on the same day, Medicare may pay the hospital discharge code (code 99238 or 99239) in addition to a nursing facility admission code when billed by the same physician with the same date of service.
12Q: How do you determine which discharge codes to bill?
Hospital Length of Stay |
Discharged On |
Code(s) to Bill |
< 8 hours |
Same calendar date as admission or start of observation |
Initial hospital services only* |
8 or more hours |
Same calendar date as admission or start of observation |
Same-day admission/discharge* |
< 8 hours |
Different calendar date than admission or start of observation |
Initial hospital services only* |
8 or more hours |
Different calendar date than admission or start of observation |
Initial hospital services* + discharge day management |
*Plus prolonged inpatient/observation services, if applicable
13Q: With 99318 being deleted for 2023, will there be a new code for the annual nursing facility assessment?
13A: No, beginning January 1, 2023, the CPT code, Other Nursing Facility Service (99318), has been deleted and is no longer used to report an annual nursing facility assessment visit on the required schedule of visits on an annual basis. Effective for dates of service on and after January 1, 2023, the regular code set for Nursing Facility services shall be used.
14Q: Would different CPT codes be used for skilled vs custodial care provided in a nursing home setting?
14A: The regular code set for Nursing Facility services shall be used for both a skilled nursing facility and a nursing facility.
15Q: Are 'incident to' services excluded in skilled nursing facilities (SNFs)?
15A: Where a physician establishes an office in a SNF/NF, the “incident to” services and requirements are confined to this part of the facility designated as his/her office. “Incident to” E/M visits, provided in a facility setting, are not payable under the physician fee schedule for Medicare Part B. Thus, visits performed outside the designated “office” area in the SNF/NF would be subject to the coverage and payment rules applicable to the SNF/NF setting and should not be reported using CPT codes for office or other outpatient visits or place of service code 11:
16Q: Can a qualified non-physician practitioner perform the initial visit in a skilled nursing facility (SNF) and/or nursing facility (NF)?
16A: The initial visit in a SNF or NF (procedure codes 99304-99306), must be performed by a physician except as otherwise permitted (42 C.F.R. 483Q:40 (c) (4)). The initial visit is defined as the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.
Further, per the long-term care regulations at 42 CFR 483Q:40 (c)(4) and (e)(2), the physician may not delegate a task that the physician must personally perform. Therefore, the physician may not delegate the initial visit in a SNF (place of service 31). This also applies to the NF (place of service 32) with one exception:
A qualified non-physician practitioner such as a nurse practitioner, physician assistant, or a clinical nurse specialist, who is not employed by the facility, may perform the initial visit when the State law permits.
17Q: If I provide a service, under arrangement to a SNF that is subject to SNF consolidated billing, what rate do we charge the SNF for the service?
17A: The SNF and provider/supplier agree to contractual terms prior to services provided. As part of this agreement, the SNF and the supplier (could be an ambulance) negotiate the terms and amount of payment. According to the
CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 6, section 10.1 , “Medicare does not prescribe the actual terms of the SNF’s relationship with its suppliers (such as the specific amount or timing of payment by the SNF), which are to be arrived at through direct negotiation between the parties to the agreement.”
18Q: Our physician provided a chest X-ray (code 71010) to a patient who is a resident of a SNF. How do we bill the chest x-ray?
18A: If the patient is in a SNF covered Part A stay, the physician/practitioner bills the professional component of the chest x-ray to Part B with modifier -26. The technical component of diagnostic tests/services is subject to SNF consolidated billing and billable by only the SNF. In this instance, the physician/practitioner looks to the SNF for payment of the technical component.
19Q: If a physician/practitioner sees a SNF resident in their office for an office visit, is the office visit billed by the physician/practitioner and if so, what place of service code is used?
19A: The professional services that the physician/practitioner performs personally are not subject to SNF consolidated billing. Therefore, if the patient was in the office, the physician/practitioner bills the office visit to Part B with place of service code 11 (office). However, services performed ‘incident to’ the physician/practitioner services are subject to SNF consolidated billing and, therefore, billed by the SNF. In this instance, the physician/practitioner looks to the SNF for payment.
20Q: Must a physician/practitioner (or any other entity) have an agreement with the SNF for services that are subject to consolidated billing?
20A: It is a best practice for a SNF to enter an arrangement with any outside provider/supplier from which the SNF's residents receive "bundled" services (services subject to SNF consolidated billing). The absence of an agreement does not relieve the SNF of its overall responsibility to furnish directly or under arrangement for all services that are subject to the consolidated billing requirement.
For additional information, please visit the CMS
Best Practices web page.
1Q: What is the difference between "new" and "established" patient and "new" and "established" problem? Does it mean the same for a non-physician practitioner (NPP)?
1A: The terms "new" or "established" problem refer to whether the problem is new or established to the examiner, e.g., physician/ NPP, and whether that problem is stable/worsening or whether the physician plans to conduct additional workup on that problem or not.
In CPT, a "new" patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the same specialty and subspecialty who belongs to the same group practice, within the past three years.
An "established" patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the same specialty and subspecialty who belongs to the same group practice, within the past three years.
CMS interprets the phrase “new patient” to mean a patient who has not received any professional services, i.e., 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 3 years. For example, if a professional component of a previous procedure is billed in a 3-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.
Currently, under the CMS enrollment process, NPPs cannot designate a sub-specialty. An NPP can only designate their primary licensure, e.g., nurse practitioner, physician assistant, certified nurse midwife, etc.
2Q: We are seeing denials for our physician’s new patient visits indicating the patient was seen by our group in the last three years. Why is this occurring? What can we do about it?
2A: In multispecialty groups, when an NPP sees the patient, this may cause your new patient visit to deny for a physician. If you can provide documentation that shows the NPP and physician are trained in different specialties, request a redetermination of the claim with the documentation.
A new patient is a patient who has not received any professional services, i.e., 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 3 years.
Currently, under the CMS enrollment process, NPPs cannot designate a sub-specialty. An NPP can only designate their primary licensure, e.g., nurse practitioner, physician assistant, certified nurse midwife, etc.
3Q: I've seen a patient in my current office within the last three years. I opened a new office in a nearby state. Will the first time I see that patient in my new office constitute a new patient visit?
3A: No, the new patient rules apply to the new location as your National Provider Identifier follows you wherever you go. A new patient is a patient who has not received any professional services, i.e., 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 3 years.
4Q: The March 2013 CPT assistant professional edition (page 8) states that providers may bill an office/outpatient E/M visit (99211-99215) for meeting with a patient’s family to discuss the patient’s care, without the patient present. Is this appropriate billing under the Medicare program?
4A: No, billing office/outpatient E/M services (99211-99215), in the absence of the patient, is not billable under the Medicare program. Medicare requires a face-to-face encounter with the patient to occur.
5Q: Can we bill a medically necessary visit on the same day as a preventive medicine service?
5A: When a physician furnishes a routine physical exam as well as a medically indicated or covered visit during the same encounter, the covered visit is viewed as being provided in lieu of a part of the routine physical. For additional billing information on preventive physical exams and other preventive services, please refer to the
preventive services page on our website.
6Q: Can E/M visits be billed on the same day as inpatient dialysis?
6A: Payment for E/M procedure codes 99231-99233 will be bundled into payment for inpatient dialysis procedures 90935-90947 for services rendered on or after January 1, 1995. No payment will be made for the E/M visits if billed the same day as inpatient dialysis.
1Q: Where can more information be found regarding incident-to services?
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
