pqri measure coding and reporting principles - Indiana Academy of ...

PQRI MEASURE CODING AND REPORTING PRINCIPLES 

PQRI Measure Denominators and Numerators 

Each PQRI measure consists of two major components: 

1. A denominator that describes the eligible cases for a measure (the eligible patient population 

associated with a measure’s numerator) 

2. A numerator that describes the clinical action required by the measure for reporting and 

performance measure denominators and numerators are further specified by specific codes, 

usually ICD-9 and CPT Category I codes for denominators and CPT Category II codes or G 

codes (where CPT Category II codes are not yet available) for numerators. Each measure is 

unique, so it is important to review and understand each measure’s specifications, which provide 

definitions and specific instructions for coding and reporting measure components. 

Use of CPT II Modifiers 

CPT II modifiers are unique to CPT II codes and may be used to report PQRI measures by appending the 

appropriate modifier to a CPT II code if allowed for a given measure. The modifiers for a code are 

mutually exclusive and their use is guided by the measure’s coding instructions, which are included in the 

numerator coding section of the PQRI Measure Specifications. Use of the modifiers is unique to CPT II 

codes and may not be used with other types of CPT codes. Descriptions of each modifier are provided 

below to help identify circumstances when the use of an exclusion modifier may be appropriate. Note that 

in a payfor-reporting model, accurate reporting on all selected applicable measures counts the same, 

whether reporting that the clinical action was performed or not. 

CPT II code modifiers fall into two categories, exclusion modifiers and the 8P reporting modifier. 

1. Exclusion modifiers may be appended to a CPT II code to indicate that an action specified in the 

measure was not provided due to medical, patient, or system reason(s) documented in the medical 

record. 

These modifiers serve as denominator exclusions for the purpose of measuring performance. 

Some measures do not provide for performance exclusions. Reasons for appending a performance 

measure exclusion modifier fall into one of three categories: 

• 1P exclusion modifier due to medical reasons 

Examples include: not indicated (absence of organ/limb, already received/performed); 

contraindicated (patient allergic history, potential adverse drug interaction) 

• 2P exclusion modifier due to patient reasons 

Examples include: patient declined; economic, social, or religious reasons 

• 3P exclusion modifier due to system reasons 

Examples include: resources to perform the services not available; insurance or 

coverage/payer-related limitations; other reasons attributable to health care delivery 

system 

2. Reporting modifier 8P is available for use only with CPT II codes to facilitate reporting an 

eligible case when an action described in a measure is not performed and the reason is not 

specified. Instructions for appending this modifier to CPT Category II codes are included in 

applicable measures. Use of the 8P reporting modifier indicates that the patient is eligible for the 

measure; however, there is no indication in the record that the action described in the measure 

was performed, nor was there any documented reason attributable to the exclusion modifiers. 

• 8P reporting modifier - action not performed, reason not otherwise specified 

The 8P modifier facilitates reporting an eligible case on a given measure when the 

clinical action does not apply to a specific encounter. Eligible professionals can use the 

*All CPT Codes, Descriptions, and Two-Digit Modifiers 

Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 

Copyright 2007 Newby Consulting, Inc. 

5-1

8P modifier to receive credit for successful reporting but will not receive credit for 

performance. 

For example, a patient with diabetes may present to a clinician for reasons that do not involve 

glycemic control, hypertension, or cholesterol management. However, the claim for services for 

that encounter will contain ICD-9 and CPT codes that will draw the patient into the diabetes 

measures’ denominator during analysis. The 8P modifier serves to include the patient in the 

numerator when reporting rates are calculated for PQRI. 

Reporting Frequency and Performance Timeframes 

Each measure includes a reporting frequency requirement for each denominator-eligible patient seen 

during the reporting period. The reporting frequency is described in the instructions: 

• Report one-time only 

• Report once for each procedure performed 

• Report once for each acute episode 

A measure’s performance timeframe is defined in the measure’s description and is distinct from the 

reporting frequency requirement. The performance timeframe, unique to each measure, delineates the 

timeframe in which the clinical action described in the numerator may be accomplished. 

Performance timeframes may be stated as “within 12 months,” or “most recent.” This means that: 

1. The clinical action in the numerator need be performed only once during a 12-month period for 

each patient seen during the reporting period 

2. The quality code need be reported only one time for each patient by each eligible professional 

caring for the patient who has chosen to report that measure during the reporting period 

If the measure calls for a clinical test result, then the most recent test result only needs to be obtained, 

assessed, and reported one time per reporting period. A test does not need to have been performed within 

the reporting period, nor does it need to have been performed by the same eligible professional. 

Performance timeframes may also be tied to a specific clinical event that requires reporting each time the 

event occurs within the reporting period. The following are examples of measures reported each time the 

clinical action described by the measure numerator is taken: 

• Procedure-related measures require reporting each time the procedure is performed and have 

distinct performance timeframes tied to them. The date of service is the date that is used to report 

the measure. Examples are perioperative care or imaging measures. 

• Chronic care measures, such as those that call for prescribing a medication, require the eligible 

professional to verify whether the medication is current and being taken by the patient. A new 

prescription is not required to meet the measure requirement unless it is clinically indicated. 

• Acute care measures are tied to specific episodes of acute care and require reporting each time an 

acute event occurs. Examples are measures related to hospitalizations, fractures and osteoporosis 

management, or stroke measures. 

Claims-Based Reporting Principles 

The following principles apply to the reporting of quality-data codes for PQRI measure 

• The CPT Category II code, which supplies the numerator, must be reported on the same claim 

form as the payment codes, usually ICD-9 and CPT Category I codes, which supply the 

denominator. 

• Quality-data codes must be submitted with a line item charge of zero dollars ($0.00) at the time 

the associated covered service is performed. 

! The submitted charge field cannot be blank. 




5-2

! The line item charge should be $0.00. 

! If a system does not allow a $0.00 line item charge, use a small amount such as $0.01 

! Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be 

$0.00) 

! Quality data code line items will be denied for payment, but are then passed through the 

claims processing system for PQRI analysis. 

• Multiple eligible professionals’ quality-data codes can be reported on the same claim. 

• Multiple CPT Category II codes for multiple measures that are applicable to a patient visit can be 

reported on the same claim, as long as the corresponding denominator codes are also line items 

on that claim. 

• The individual NPI of the participating eligible professional(s) must be properly used on the 

claim. 

Timeliness of Quality Data Submission 

Claims processed by the Carrier/MAC must reach the national Medicare claims system data warehouse 

(National Claims History file) by February 29, 2008 to be included in the analysis. Claims for services 

furnished toward the end of the reporting period should be filed promptly. Claims that are resubmitted 

only to add quality-data codes will not be included in the analysis. 

Successful Reporting 

The 2007 PQRI incentive payment is an all-or-nothing bonus (subject to cap) based on successful 

reporting. 

Eligible professionals need not enroll or file an intent to participate for the PQRI. Eligible professionals 

can participate by reporting the appropriate quality measure data on claims submitted to their Medicare 

claims processing contractor. 

In order to satisfactorily meet the requirements of the program and receive the bonus payment, certain 

reporting thresholds must be met. When four or more measures are applicable to the services provided by 

an eligible professional, the 80% threshold must be met on at least three of the measures reported. 

Good news for those physicians practicing in a group practice, not all physicians in the group must 

participate in PQRI to be eligible for the bonus payment. Individual analysis will be done using the 

individual physician’s national provider identifier (NPI) to determine satisfactory reporting and the bonus 

payment calculation. Thus, physicians must bill with an NPI to participate in PQRI. The potential 1.5 

percent incentive payment will be paid in mid-2008 as a lump-sum bonus payment made to the practice at 

the Taxpayer Identification Number (TIN) level. According to the CMS website, the NPI is the only 

unique provider enumerator that can be used by the CMS PQRI analysis contractor to properly identify 

eligible physicians at the individual-physician level. 

The performing professional’s NPI must be used for the quality-data codes and related services. For 

claims submitted via the ASC X12N 837 professional health care claim transaction, the group practice 

NPI is placed in the provider billing segment, loop 2010AA, and the performing professional’s NPI is 

placed in loop 2420A. For claims submitted via the CMS 1500 form, the performing professional’s NPI is 

placed on the individual line item. Placing the performing eligible professional’s NPI on the individual 

line item will allow the analysis of successful reporting and the bonus payment calculation to be 

performed at the individual level, though payment will be made at the TIN level. 

Bonus Payment 

Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap. The 

potential 1.5% bonus will be based on allowed charges for covered professional services: 




5-3

1. Furnished during the reporting period of July 1 through December 31, 2007, 

2. Received into the CMS National Claims History (NCH) file by February 29, 2008 (Joy’s 

comment: claim should be received by the Carrier no later than February 28, 2008), and 

3. Paid under the Medicare Physician Fee Schedule (Joy’s comment: HCPCS “J” codes for drugs 

are not subject to the bonus). 

Because claims processing times may vary by time of the year and Medicare Carrier/Medicare 

Administrative Contractor (MAC), physicians should submit claims from the end of 2007 promptly, so 

that those claims will reach the NCH file by February 29, 2008. Bonuses will be paid as a lump sum in 

mid-2008. There is no beneficiary copayment or notice to the beneficiary regarding the bonus payments. 

A payment cap that would reduce the potential bonus below 1.5% of allowed charges may apply in 

situations where a physician reports relatively few instances of quality measure data. The physician’s cap 

will be calculated by multiplying: (1) the physician’s total instances of reporting quality data for all 

measures (not limited only to measures meeting the 80% threshold), by (2) a constant of 300%, and by (3) 

the national average per measure payment amount. 

The national average per measure payment amount is one value for all measures and all participants that 

is calculated by dividing: (1) the total amount of allowed charges under the Physician Fee Schedule for all 

covered professional services furnished during the reporting period on claims for which quality measures 

were reported by all participants in the program by (2) the total number of instances for which data were 

reported by all participants in the program for all measures during the reporting period. (Note that the 

national average per measure payment amount calculation only takes into account the charges on claims 

for which quality measures were reported, whereas the individual bonus calculation takes into account 

charges for all services furnished during the reporting period.) While the purpose of the cap is clear, it is 

not possible to determine the impact of the cap until the national average per measure payment amount 

can be calculated after the end of the reporting period. 

CMS recommends that physicians report on every quality measure that is applicable to their patient 

populations to: (1) increase the likelihood that they will reach the 80% satisfactorily reporting 

requirement for the requisite number of measures and (2) increase the likelihood that they will not be 

affected by the bonus payment cap. 

2007 Physician Quality Reporting Initiative Measures - Not All Inclusive 

1) Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus - Percentage of patients aged 18-75 

years with diabetes (type 1 or type 2) who had most recent hemoglobin A1c greater than 9.0% - This measure is to 

be reported a minimum of once per reporting period for patients seen during the reporting period. The performance 

period for this measure is 12 months. It is anticipated that clinicians who provide services for the primary 

management of diabetes mellitus will submit this measure 

ICD-9: 250.00-250.93, 648.00-648.04 and CPT: 99201-99215 (office/outpatient visit) (office/outpatient visit); 99341-99350 (home visit); 

99304-99310 (nursing facility); 99324-99337 (domiciliary); 97802-97804 and G0270-G0271 (nutrition therapy) 

_____ 

_____ 

_____ 

_____ 

Most recent hemoglobin A1c level > 9.0% (3046F) 

Most recent hemoglobin A1c level < 7.0% (3044F) 

Most recent hemoglobin A1c level 7.0% to 9.0% (3045F) 

Hemoglobin A1c not performed during last 12 months reason not specified (3046F-8P) 

2) Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus - Percentage of patients aged 18-75 

years with diabetes (type 1 or type 2) who had most recent LDL-C level in control (less than 100 mg/dl) - This 

measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The 

performance period for this measure is 12 months. It is anticipated that clinicians who provide services for the 

primary management of diabetes mellitus will submit this measure. 




5-4

ICD-9: 250.00-250.93, 648.00-648.04 and CPT: 99201-99215 (office/outpatient visit) (office/outpatient visit); 99341-99350 (home visit); 

99304-99310 (nursing facility); 99324-99337 (domiciliary); 97802-97804 and G0270-G0271 (nutrition therapy) 

_____ 

_____ 

_____ 

_____ 

Most recent LDL-C < 100 mg/dL (3048F) 

Most recent LDL-C 100-129 mg/dL (3049F) 

Most recent LDL-C ≥ 130 mg/dL (3050F) 

LDL-C level not performed during last 12 months reason not specified (3048F-8P) 

3) High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus - Percentage of patients aged 18-75 

years with diabetes (type 1 or type 2) who had most recent blood pressure in control (less than 140/80 mm Hg) - 

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. 

The performance period for this measure is 12 months. It is anticipated that clinicians who provide services for the 

primary management of diabetes mellitus will submit this measure. 

ICD-9: 250.00-250.93, 648.00-648.04 and CPT: 99201-99215 (office/outpatient visit); 99341-99350 (home visit); 99304-99310 (nursing 

facility); 99324-99337 (domiciliary); 97802-97804 and G0270-G0271 (nutrition therapy) 

Systolic codes 

_____ Most recent systolic blood pressure < 130 mm Hg (3074F) 

_____ Most recent systolic blood pressure 130 to 139 mm Hg (3075F) 

_____ Most recent systolic blood pressure > 140 mm Hg (3077F) 

AND 

Diastolic codes 

_____ Most recent diastolic blood pressure < 80 mm Hg (3078F) 

_____ Most recent diastolic blood pressure 80-89 mm Hg (3079F) 

_____ Most recent diastolic blood pressure > 90 mm Hg (3080F) 

OR 

_____ 

Blood pressure measurement not performed, reason not specified (2000F-8P) 

4) Screening for Future Fall Risk - Percentage of patients aged 65 years and older who were screened for 

future fall risk (patients are considered at risk for future falls if they have had 2 or more falls in the past year or any 

fall with injury in the past year) at least once within 12 months - This measure is to be reported a minimum of once 

per reporting period for patients seen during the reporting period. This measure is appropriate for use in all nonacute 

settings (excludes emergency departments and acute care hospitals). It is anticipated that clinicians who 

provide primary care for the patient will submit this measure. 

ICD-9: None specified - CPT: 97001-97004 (PT eval); 99201-99215 (office/outpatient visit), 99304-99310 (nursing facility), 99324-99328 

(domiciliary), 99334-99337 (domiciliary), 99341-99350 (home visits), 99387 and 99397 (preventive), 99401-99404 (preventive counseling), 

Definition: A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower 

level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic 

seizure, or overwhelming external force (Tinetti). 

_____ 

_____ 

_____ 

_____ 

Screening for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the 

past year (1100F) 

Screening for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the 

past year (1101F) 

Screening for future fall risk not performed for medical reasons (1100F-1P) 

Screening for future fall risk not performed, reason not specified (1100F-8P) 

5) Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor 

Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) - Percentage of patients aged 

18 years and older with a diagnosis of heart failure and left ventricular systolic dysfunction (LVSD) who were 

prescribed ACE inhibitor or ARB therapy - This measure is to be reported a minimum of once per reporting period 

for all heart failure patients seen during the reporting period. The left ventricular systolic dysfunction may be 




5-5

determined by quantitative or qualitative assessment. Examples of a quantitative or qualitative assessment may 

include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses 

descriptive terms such as moderately or severely depressed left ventricular dysfunction. It is anticipated that 

clinicians who provide primary management of patients with heart failure will submit this measure. 

ICD-9: 402.01, 402.11, 402.91; 404.01, 404.03, 404.11, 404.13, 404.91, 404.93; 428.0, 428.1, 428.20-428.23, 428.30-428.33, 428.40-428.43, 

428.9 and CPT: 99201-99215 (office/outpatient visit), 99238, 99239 (discharge), 99241-99245 (office/outpatient consult), 99304-99310 

(nursing facility), 99324-99337 (domiciliary), 99341-99350 (home visit) 

_____ 

OR 

_____ 

_____ 

_____ 

AND 

_____ 

_____ 

_____ 

ACE inhibitor or ARB therapy prescribed and left ventricular ejection fraction (LVEF)

_____ 

_____ 

_____ 

_____ 

_____ 

Beta-blocker therapy prescribed (4006F) 

Documentation of medical reason(s) for not prescribing beta-blocker therapy (4006F-1P) 

Documentation of patient reason(s) for not prescribing beta-blocker therapy (4006F-2P) 

Documentation of system reason(s) for not prescribing beta-blocker therapy (4006F-3P) 

Beta-blocker therapy not prescribed, reason not specified (4006F-8P) 

8) Heart Failure: Beta-blocker Therapy for Left Ventricular Systolic Dysfunction - Percentage of 

patients aged 18 years and older with a diagnosis of heart failure who also have left ventricular systolic dysfunction 

(LVSD) and who were prescribed beta-blocker therapy - This measure is to be reported a minimum of once per 

reporting period for all heart failure patients seen during the reporting period. The left ventricular systolic 

dysfunction may be determined by quantitative or qualitative assessment. Examples of a quantitative or qualitative 

assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic 

dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular dysfunction. It 

is anticipated that clinicians who provide primary management of patients with heart failure will submit this 

measure. 

ICD-9: 402.01, 402.11, 402.91; 404.01, 404.03, 404.11, 404.13, 404.91, 404.93; 428.0, 428.1, 428.20-428.23, 428.30-428.33, 428.40-428.43, 

428.9 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult), 99341-99350 (home visit), 99304-99310 

(nursing facility), 99324-99337 (domiciliary) 

_____ 

Beta blocker therapy prescribed and left ventricular ejection fraction (LVEF) < 40% or documentation of 

moderately or severely depressed left ventricular systolic function (4006F and 3021F) 

OR 

_____ 

_____ 

_____ 

Documentation of medical reason(s) for not prescribing beta-blocker therapy (4006F-1P) 

Documentation of patient reason(s) for not prescribing beta-blocker therapy (4006F-2P) 

Documentation of system reason(s) for not prescribing beta-blocker therapy (4006F-3P) 

AND 

_____ 

_____ 

_____ 

Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left 

ventricular systolic function (3021F) 

Left ventricular ejection fraction (LVEF) ≥ 40% or documentation as normal or mildly depressed left 

ventricular systolic function (3022F) 

Left ventricular ejection fraction (LVEF) was not performed or documented, reason not otherwise specified 

(3021F-8P) 

OR 

_____ 

Beta-blocker therapy was not prescribed, reason not otherwise specified and left ventricular ejection 

fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic 

function (4006F-8P and 3021F) 

9) Antidepressant Medication During Acute Phase for Patients with New Episode of Major 

Depression - Percentage of patients aged 18 years and older diagnosed with new episode of major depressive 

disorder (MDD) and documented as treated with antidepressant medication during the entire 84-day (12 week) acute 

treatment phase - This measure is to be reported for each occurrence of MDD during the reporting period. It is 

anticipated that clinicians who provide the primary management of patients with major depressive disorder (MDD) 

will submit this measure. 

ICD-9: 296.20-296.24, 296.30-296.34, 298.0, 300.4, 309.1, 311 and CPT: 99201-99215 (office/outpatient visit); 90801, 90802, 90804-90809, 

90862 (psychiatry) 

Definition: A “new episode” is defined as a patient with major depression who has not been seen or treated for 

major depression by any practitioner in the prior 4 months. A new episode can either be a recurrence for a patient 

with prior major depression or a patient with a new onset of major depression. 




5-7

Report G8126: 1) For all patients with a diagnosis of Major Depression, New Episode who were prescribed a full 

12 week course of antidepressant medication OR 2) At the completion of a 12 week course of antidepressant 

medication. 

_____ 

_____ 

_____ 

Patient with new episode of MDD documented as being treated with antidepressant medication during the 

entire 12 week acute treatment phase (G8126) 

Patient with new episode of MDD not documented as being treated with antidepressant medication during 

the entire 12 week acute treatment phase (G8127) 

Clinician documented that patient with a new episode of MDD was not an eligible candidate for 

antidepressant medication treatment or patient did not have a new episode of MDD (G8128) 

39) Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older - Percentage of 

female patients aged 65 years and older who have a central dual-energy X-ray absorptiometry (DXA) measurement 

ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months - This 

measure is to be reported a minimum of once during the reporting period for patients seen during the reporting 

period. Female patients aged 65 years and older should have a central DXA measurement ordered or performed at 

least once since the time they turned 60 years or have pharmacologic therapy prescribed to prevent or treat 

osteoporosis. It is anticipated that clinicians who provide primary care or care for treatment of fracture or 

osteoporosis will submit this measure. 

ICD-9: No specific diagnosis codes and CPT: 99201-99215 (office/outpatient visit), 99387 and 99397 (preventive), 99401-99404 (preventive 

counseling) 

Definition: Pharmacologic Therapy: U.S. Food and Drug Administration approved pharmacologic options for 

osteoporosis prevention and/or treatment of postmenopausal osteoporosis include, in alphabetical order: 

bisphosphonates (alendronate, ibandronate, and risedronate), calcitonin, estrogens (estrogens and/or hormone 

therapy), parathyroid hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs 

(raloxifene). 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

Central Dual-energy X-Ray Absorptiometry (DXA) ordered (3096F) 

Central Dual-energy X-Ray Absorptiometry (DXA) results documented (3095F) 

Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed (4005F) 

Documentation of medical reason(s) for not ordering or performing a central dual energy X-ray 

absorptiometry (DXA) measurement or not prescribing pharmacologic therapy for osteoporosis (3096F-1P) 

Documentation of patient reason(s) for not ordering or performing central dual energy X-ray 


Documentation of system reason(s) for not ordering or performing central dual energy X-ray 


Central dual energy X-ray absorptiometry (DXA) measurement was not ordered or performed and a 

pharmacologic therapy for osteoporosis was not prescribed reason not otherwise specified (3096F-8P) 

40) Osteoporosis: Management Following Fracture - Percentage of patients aged 50 years and older with 

fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement 

ordered or performed or pharmacologic therapy prescribed - This measure is to be reported after each occurrence of 

a fracture during the reporting period. Patients with a fracture of the hip, spine, or distal radius should have a central 

DXA measurement ordered or performed or pharmacologic therapy prescribed. The management (DXA ordered or 

performed or pharmacologic therapy prescribed) should occur within three months of the initial visit with the 

reporting clinician following the fracture. Patients with documentation of prior central DXA measurement or already 

receiving pharmacologic therapy would automatically meet the intent of this measure. It is anticipated that clinicians 

who manage the primary or ongoing care for osteoporosis or osteoporosis related fracture(s) will submit this 

measure. 

ICD-9: 733.12-733.14, 805.00-805.08, 805.10-805.18, 805.2, 805.4, 805.6, 805.8, 813.40-813.42, 813.44, 813.45, 813.50-813.52, 813.54, 

820.00-820.03, 820.09-820.11, 820.20-820.22, 820.13. 820.8, 820.9 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office 

consult) 




5-8





(raloxifene). 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

Central dual energy X-ray absorptiometry (DXA) ordered (3096F) 

Central dual energy X-ray absorptiometry (DXA) results documented (3095F) 


Documentation of medical reason(s) for not ordering or performing a central dual energy X-ray 


Documentation of patient reason(s) for not ordering or performing a central dual energy X-ray 


Documentation of system reason(s) for not ordering or performing a central dual energy X-ray 


Central dual energy X-ray absorptiometry (DXA) measurement was not ordered or performed and a 

pharmacologic therapy for osteoporosis was not prescribed reason not otherwise specified (3096F-8P) 

41) Osteoporosis: Pharmacologic Therapy - Percentage of patients aged 50 years and older with a diagnosis 

of osteoporosis who were prescribed pharmacologic therapy within 12 months - This measure is to be reported a 

minimum of once per reporting period for patients seen during the reporting period. Patients with a diagnosis of 

osteoporosis should be prescribed pharmacologic therapy to treat osteoporosis. It is anticipated that clinicians who 

provide services for patients with the diagnosis of osteoporosis will submit this measure. 

ICD-9: 733.00-733.03, 733.09 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult), 99386-99387 and 

99396- 99397 (preventive), 99401-99404 (preventive counseling) 





(raloxifene). 

_____ 

_____ 

1P) 

_____ 

_____ 

_____ 


Documentation of medical reason(s) for not prescribing pharmacologic therapy for osteoporosis (4005F- 

Documentation of patient reason(s) for not prescribing pharmacologic therapy for osteoporosis (4005F-2P) 

Documentation of system reason for not prescribing pharmacologic therapy for osteoporosis (4005F-3P) 

Pharmacologic therapy for osteoporosis was not prescribed reason not otherwise specified (4005F-8P) 

42) Osteoporosis: Counseling for Vitamin D, Calcium Intake, and Exercise - Percentage of patients, 

regardless of age, with a diagnosis of osteoporosis who are either receiving both calcium and vitamin D or have 

been counseled regarding both calcium and vitamin D intake, and exercise at least once within 12 months - This 

measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. 

Patients with a diagnosis of osteoporosis should be receiving both calcium and vitamin D or had counseling 

regarding their use and counseled on exercise. It is anticipated that clinicians who provide services for patients with 

the diagnosis of osteoporosis will submit this measure. 

ICD-9: 733.00-733.03, 733.09 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult), 99385-99387 and 

99395-99397 (preventive), 99401-99404 (preventive counseling) 

_____ 

_____ 

_____ 

Documentation of receipt of counseling on exercise AND either both calcium and vitamin D use or 

counseling regarding both calcium and vitamin D use (4019F) 

Documentation of medical reason(s) for patient not receiving both calcium and vitamin D or and not 

needing counseling regarding both calcium and vitamin D intake, and exercise (e.g., patient has dementia 

and is unable to receive counseling) (4019F-1P) 

Receipt of counseling on exercise AND either both calcium and vitamin D use or counseling regarding 

both calcium and vitamin D use was not documented reason not otherwise specified (4019F-8P) 




5-9

46) Medication Reconciliation - Percentage of patients aged 65 years and older discharged from any inpatient 

facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge 

in the office by the physician providing on-going care who had a reconciliation of the discharge medications with 

the current medication list in the medical record documented - This measure is to be reported at an office visit 

occurring within 60 days of each inpatient facility discharge during the reporting period. This measure is appropriate 

for use in the ambulatory setting only. It is anticipated that clinicians who provide primary on-going care will submit 

this measure when a patient is seen in the office within 60 days following discharge from any inpatient facility. If a 

patient has not been discharged within the 60-day timeframe from an inpatient facility, there are no reporting 

requirements for this measure. 

ICD-9: No specific diagnosis code and CPT: 99201-99215 (office/outpatient visit), 99387 and 99397 (preventive), 99401-99404 (preventive 

counseling) 

_____ 

_____ 

Patient discharged from an inpatient facility within the last 60 days and discharge medications reconciled 

with the current medication list in outpatient medical record (1110F and 1111F) 

Patient discharged from an inpatient facility within the last 60 days and discharge medication not 

reconciled with current medication list in the medical record, reason not specified (1110F and 1111F-8P) 

47) Advance Care Plan - Percentage of patients aged 65 years and older with documentation of a surrogate 

decision-maker or advance care plan in the medical record - This measure is to be reported a minimum of once per 

reporting period for patients seen during the reporting period. This measure is appropriate for use in all healthcare 

settings. It is anticipated that clinicians who provide primary care services for the patient will submit this measure. 

ICD-9: No specific diagnosis codes and CPT: 99201-99215 (office/outpatient visit), 99218-99220 (observation services), 99221-99223 (initial 

inpatient), 99231-99233 (subsequent inpatient), 99234-99236 (admit and discharge on the same day), 99281-99285 (ED services), 99291 

(critical care), 99304-99310 (nursing facility), 99324-99337 (domiciliary/rest home), 99341-99350 (home visits), 99387 and 99397 

(preventive services), 99401-99404 (preventive counseling) 

_____ 

_____ 

_____ 

Surrogate decision maker or advance care plan documented in the medical record (1080F) 

Surrogate decision maker or advance directive not documented for patient reasons (1080F-2P) 

Surrogate decision maker or advance directive not documented, reason not specified (1080F-8P) 

(Joy’s Comment: For successful reporting of this measure, primary care physicians will have to report on this 

measure at least one time for every Medicare patient.) 

48) Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and 

Older - Percentage of female patients aged 65 years and older who were assessed for the presence or absence of 

urinary incontinence within 12 months - This measure is to be reported a minimum of once per reporting period for 

patients seen during the reporting period. This measure is appropriate for use in the ambulatory setting only. It is 

anticipated that clinicians who provide primary care for the patient will submit this measure. 

ICD-9: No specific codes and CPT: 99201-99215 (office/outpatient visit), 99387 and 99397 (preventive), 99401-99404 (preventive 

counseling) 

Definition: Urinary incontinence is defined as any involuntary leakage of urine. 

_____ 

_____ 

_____ 

Presence or absence of urinary incontinence assessed (1090F) 

Presence or absence of urinary incontinence not assessed for medical reasons (1090F-1P) 

Presence or absence of urinary incontinence not assessed reason not specified (1090F-8P) 

49) Characterization of Urinary Incontinence in Women Aged 65 Years and Older - Percentage of 

female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was 

characterized at least once within 12 months - This measure is to be reported a minimum of once per reporting 

period for patients seen during the reporting period. This measure is appropriate for use in the ambulatory setting 

only. It is anticipated that clinicians who provide services for patients with the diagnosis of urinary incontinence will 

submit this measure. 

ICD-9: 307.6, 625.6, 788.30-788.39 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult), 99387 and 99397 

(preventive), 99401-99404 (preventive counseling) 

5-10 



Copyright 2007 Newby Consulting, Inc.

Definition: Characterization includes, but is not limited to, (frequency, volume, timing, type of symptoms, how 

bothersome) 

_____ 

_____ 

Urinary incontinence characterized (1091F) 

Urinary incontinence not characterized reason not specified (1091F-8P) 

50) Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older - Percentage of female 

patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary 

incontinence at least once within 12 months - This measure is to be reported a minimum of once per reporting period 

for patients seen during the reporting period. This measure is appropriate for use in the ambulatory setting only. It is 

anticipated that clinicians who provide services for patients with the diagnosis of urinary incontinence will submit 

this measure. 

ICD-9: 307.6, 625.6, 788.30-788.39 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult), 99387 and 99397 

(preventive), 99401-99404 (preventive counseling) 

Definition: Plan of care may include behavioral interventions (e.g., bladder training, pelvic floor muscle training, 

prompted voiding), referral to specialist, surgical treatment, reassess at follow-up visit, lifestyle interventions, 

addressing co-morbid factors, modification or discontinuation of medications contributing to urinary incontinence, 

or pharmacologic therapy. 

_____ 

_____ 

Urinary incontinence plan of care documented (0509F) 

Plan of care for urinary incontinence not documented reason not specified (0509F-8P) 

51) Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation - Percentage of patients 

aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented - This 

measure is to be reported a minimum of once per reporting period using the most recent spirometry results in the 

patient record for patients seen during the reporting period. It is anticipated that clinicians who provide primary care 

services for the patient will submit this measure. 

ICD-9: 491.0, 491.1, 491.20-491.22, 491.8, 491.9, 492.0, 492.8, 496 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 

(office/outpatient consult), 99385-99387, 99395-99397 (preventive), 99401-99404 (preventive counseling) 

Instructions: Look for most recent documentation of spirometry evaluation results in the medical record; do not 

limit the search to the reporting period. 

_____ 

_____ 

_____ 

_____ 

_____ 

Spirometry results documented and reviewed (3023F) 

Spirometry results not documented medical reason(s) (3023F-1P) 

Spirometry results not documented for patient reasons (3023F-2P) 

Spirometry results not documented for system reasons (3023F-3P) 

Spirometry results not documented, reason not specified (3023F-8P) 

52) Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy - Percentage of patients 

aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70% and have symptoms 

who were prescribed an inhaled bronchodilator - This measure is to be reported a minimum of once per reporting 

period for all COPD patients seen during the reporting period. It is anticipated that clinicians who provide primary 

care services for the patient will submit this measure. 

ICD-9: 491.0, 491.1, 491.20-491.22, 491.8, 491.9, 492.0, 492.8, 496 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 

(office/outpatient consult), 99385-99387, 99395-99397 (preventive), 99401-99404 (preventive counseling) 

_____ 

_____ 

_____ 

Inhaled bronchodilator prescribed and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD 

symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F and 3025F) 

Documentation of medical reason(s) for not prescribing an inhaled bronchodilator and spirometry test 

results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) 

(4025F-1P and 3025F) 

Documentation of patient reason(s) for not prescribing an inhaled bronchodilator and spirometry test results 

demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-2P 

and 3025F) 

5-11 




_____ 

_____ 

_____ 

_____ 

Documentation of system reason(s) for not prescribing an inhaled bronchodilator and spirometry test results 

demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-3P 


Spirometry results demonstrate FEV 1 /FVC ≥ 70% or patient does not have COPD symptoms (3027F) 

Spirometry test not performed or documented (3025F-8P) 

Inhaled bronchodilator not prescribed, reason not specified and spirometry test results demonstrate 

FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-8P and 3025F) 

53) Asthma: Pharmacologic Therapy - Percentage of patients aged 5 to 40 years with a diagnosis of mild, 

moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication 

(inhaled corticosteroid) or an acceptable alternative treatment - This measure is to be reported a minimum of once 

per reporting period for all asthma patients seen during the reporting period. It is anticipated that clinicians who 

provide primary care services for the patient will submit this measure. 

ICD-9: 493.00-493.02, 493.10-493.12, 493.20-493.22, 493.81, 493.82, 493.90, 493.92 and CPT: 99201-99215 (office/outpatient visit), 99241- 

99245 (office/outpatient consult), 99383-99386, 99393-99396 (preventive), 99401-99404 (preventive counseling) 

Definition: acceptable alternative treatment (leukotriene modifiers, cromolyn sodium, nedocromil sodium, or 

sustained-released methylxanthines) 

_____ 

_____ 

_____ 

_____ 

Persistent asthma (mild, moderate, or severe) and preferred long term control medication or acceptable 

alternative treatment prescribed (4015F and 1038F) 

Persistent asthma (mild, moderate, or severe) and preferred long-term control medication or acceptable 

alternative treatment not prescribed for patient reasons (4015F-2P and 1038F) 

Intermittent asthma (1039F) 

Persistent asthma (mild, moderate, or severe) and preferred long-term control medication or acceptable 

alternative treatment not prescribed, reason not specified (4015F-8P and 1038F) 

60) Gastroesophageal Reflux Disease (GERD): Assessment for Alarm Symptoms - Percentage of 

patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who were assessed for the 

presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding - This 

measure is to be reported once for all GERD patients seen during the reporting period. Patients seen for an initial 

evaluation of GERD should have documentation in the medical record of the presence or absence of alarm 

symptoms. If the initial evaluation of GERD occurred prior to the reporting period, report the proper CPT Category 

II code with modifier indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated 

that clinicians who provide care for patients with GERD will submit this measure. 

ICD-9: 530.81, 530.10-530.12, 530.19 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult) 

Definition: Patients assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, 

dysphagia, and GI bleeding 

_____ 

_____ 

_____ 

_____ 

_____ 

Alarm symptoms assessed; none present (1070F) 

Alarm symptoms assessed; one or more present (1071F) 

Patient does not meet denominator inclusion because the initial evaluation of GERD occurred prior to the 

reporting period (1070F-8P) 

Alarm symptoms not assessed for medical reasons (1070F-1P) 

Alarm symptoms not assessed, reason not specified (1071F-8P) 

(Joy’s Comment: For successful reporting of this measure, physicians will have to report on this measure at least 

one time for every Medicare patient with GERD.) 

61) Gastroesophageal Reflux Disease (GERD): Upper Endoscopy for Patients with Alarm 

Symptoms - Percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial 

evaluation, with at least one alarm symptom who were either referred for upper endoscopy or had an upper 

endoscopy performed - This measure is to be reported once for all GERD patients seen during the reporting period. 

Patients seen for an initial evaluation of GERD and at least one alarm symptom will be referred for upper endoscopy 

or have an upper endoscopy performed. If the initial evaluation of GERD occurred prior to the reporting period, 

5-12 




eport the proper CPT II Category II code with modifier indicated in the numerator coding indicating this is not the 

initial evaluation. It is anticipated that clinicians who provide care for patients with GERD will submit this measure. 


Definition: Alarm symptoms for GERD include involuntary weight loss, dysphagia, and GI bleeding. 

_____ Upper gastrointestinal endoscopy performed (3130F) 

_____ Documentation of referral for upper gastrointestinal endoscopy (3132F and 1071F) 

_____ Patient does not have alarm symptoms (1070F) 

_____ Initial evaluation of GERD occurred prior to the reporting period (1071F-8P) 

_____ Upper endoscopy not performed or patient not referred for upper endoscopy for medical reasons (e.g., 

patient has already had the procedure) (3130F-1P and 1071F) 

_____ Upper endoscopy not performed or patient not referred for upper endoscopy for patient reasons (3130F-2P 


_____ Upper endoscopy not performed or patient not referred for upper endoscopy for system reasons (3130F-3P 


_____ Upper endoscopy not performed or patient not referred for upper endoscopy, reason not specified (3130F- 

8P and 1071F) 

(Joy’s Comment: For successful reporting of this measure, physicians will have to report on this measure and 

measure #60 at least one time for every Medicare patient with GERD.) 

63) Gastroesophageal Reflux Disease (GERD): Barium Swallow- Inappropriate Use - Percentage of 

patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who did not have a 

Barium swallow test ordered - This measure is to be reported once for all GERD patients seen during the reporting 

period. Patients being seen for an initial evaluation of GERD should not receive a barium swallow test. If the initial 

evaluation of GERD occurred prior to the reporting period, report the proper CPT Category II with modifier 

indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated that clinicians who 

provide care for patients with GERD will submit this measure. 


Definitions: This is an overuse measure. For performance, the numerator will be calculated as the difference 

between patients in the denominator and patients for whom a CPT Category II code was reported for barium 

swallow test ordered. A higher score indicates appropriate treatment of patients with GERD (i.e., the proportion for 

whom a barium swallow test was not ordered). 

_____ 

_____ 

_____ 

_____ 

Barium swallow test ordered (3142F) 

Patient does not meet denominator inclusion because the initial evaluation of GERD occurred prior to the 

reporting period (3200F-8P) 

Barium swallow test ordered for medical reasons (3142F-1P) 

Barium swallow test not ordered (3200F) 

(Joy’s Comment: For successful reporting of this measure, physicians will have to report on this measure and 

measure #60 at least one time for every Medicare patient with GERD.) 

64) Asthma Assessment - Percentage of patients aged 5 to 40 years with a diagnosis of asthma who were 

evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal 

asthma symptoms - This measure is to be reported a minimum of once per reporting period for patients seen during 

the reporting period. It is anticipated that clinicians who provide primary care services for the patient with a 

diagnosis of asthma will submit this measure. 

ICD-9: 493.00-493.02, 493.10-493.12, 493.20-493.22, 493.81, 493.82, 493.90, 493.92 and CPT: 99201-99215 (office/outpatient visit), 99241- 

99245 (office/outpatient consult), 99383-99386, 99393-99396 (preventive), 99401-99404 (preventive counseling) 

Definitions: To be counted in calculations of this measure, symptom frequency must be numerically quantified. 

Measure may also be met by clinician documentation or patient completion of an asthma assessment 

5-13 




tool/survey/questionnaire. Assessment tool may include the Quality Metric Asthma Control Test, National Asthma 

Education & Prevention Program (NAEPP) Asthma Symptoms and Peak Flow Diary. 

_____ 

_____ 

Asthma symptoms evaluated (includes physician documentation of numeric frequency of symptoms or 

patient completion of an asthma assessment tool/survey/questionnaire) (1005F) 

Asthma symptom frequency not evaluated, reason not specified (1005F-8P) 

PAYMENT FOR EVALUATION AND MANAGEMENT SERVICES 

PROVIDED DURING GLOBAL PERIOD OF SURGERY 

Medicare Claims Processing Manual Chapter 12 §30.6.6 (Rev. 954, Issued: 05-19-06, Effective: 06-01- 

06, Implementation: 08-20-06) 

CPT Modifier -24 - Unrelated Evaluation and Management Service by Same Physician during 

Postoperative Period 

Carriers pay for an evaluation and management service other than inpatient hospital care before discharge 

from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative 

period of a surgical procedure, furnished by the same physician who performed the procedure, billed with 

CPT modifier -24, and accompanied by documentation that supports that the service is not related to the 

postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during 

the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition 

that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred 

is compensated through the global surgical payment. 

CPT Modifier -25 - Significant Evaluation and Management Service by Same Physician on Date of 

Global Procedure 

Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on 

claims for evaluation and management (E/M) services, and only when these services are provided by the 

same physician (or same qualified nonphysician practitioner) to the same patient on the same day as 

another procedure or other service. Carriers pay for an E/M service provided on the day of a procedure 

with a global fee period if the physician indicates that the service is for a significant, separately 

identifiable E/M service that is above and beyond the usual pre- and post-operative work of the 

procedure. Different diagnoses are not required for reporting the E/M service on the same date as the 

procedure or other service. Modifier -25 is added to the E/M code on the claim. 

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently 

documented by the physician or qualified nonphysician practitioner in the patient’s medical record to 

support the claim for these services, even though the documentation is not required to be submitted with 

the claim. 

CPT Modifier -57 - Decision for Surgery Made Within Global Surgical Period 

Carriers pay for an evaluation and management service on the day of or on the day before a procedure 

with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service 

resulted in the decision to perform the procedure. Carriers may not pay for an evaluation and management 

service billed with the CPT modifier -57 if it was provided on the day of or the day before a procedure 

with a 0 or 10-day global surgical period. 

Payment for Evaluation and Management Services Provided During Global Period of Surgery 

• The Centers for Medicare & Medicaid Services (CMS) has clarified the documentation 

requirements and policy requirements for the use of CPT modifier -25 used with E/M services. 

Please refer to the manual attachment to CR5025, The Medicare Claims Processing Manual, 

Chapter 12, §30.6.6, for revisions regarding the use of CPT modifier -25 

5-14 




• Physicians and qualified nonphysician practitioners (NPP) should use CPT modifier -25 to 

designate a significant, separately identifiable E/M service provided by the same 

physician/qualified NPP to the same patient on the same day as another procedure or other 

service with a global fee period. 

• Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately 

identifiable evaluation and management (E/M) service. It should be used when the E/M service is 

above and beyond the usual pre- and postoperative work of a procedure with a global fee period 

performed on the same day as the E/M service. 

• Different diagnoses are not required for reporting the E/M service on the same date as the 

procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the 

claim. 

• Both the medically necessary E/M service and the procedure must be appropriately and 

sufficiently documented by the physician or qualified NPP in the patient’s medical record to 

support the need for modifier -25 on the claim for these services, even though the documentation 

is not required to be submitted with the claim. 

• Your Carrier will not retract payment for claims already paid or retroactively pay claims 

processed prior to the implementation of CR5025. But, they will adjust claims brought to their 

attention. 

• Carriers will not pay for an E/M service reported with a procedure having a global fee period 

unless CPT modifier -25 is appended to the E/M service to designate it as a significant and 

separately identifiable E/M service from the procedure. 

PREOPERATIVE SERVICES 

§1862(a)(1)(A) of the Social Security Act requires that in order to qualify for Medicare coverage, a 

service must be reasonable and necessary for the diagnosis and treatment of illness or injury, or to 

improve the functioning of a malformed body member. A preoperative service performed due to hospital 

or malpractice protocol cannot supercede this guideline for Medicare coverage purposes. Medicare will 

pay for preoperative evaluation and management services, and diagnostic tests if they are medically 

necessary and meet the documentation requirements of the service rendered. 

CMS Transmittal #1707 – May 31, 2001 

A. General--This manual instruction addresses payment for preoperative services that are not included in 

the global surgery payment. 

B. Non-global Preoperative Services -- Consist of evaluation and management (E/M) services 

(preoperative examinations) that are not included in the global surgical package and diagnostic tests 

performed for the purpose of evaluating a patient's risk of perioperative complications and optimizing 

perioperative care. Medicare will pay for all medically necessary preoperative. 

C. Non-global Preoperative Examinations -- E/M services performed that are not included in the global 

surgical package for evaluating a patient's risk of perioperative complications and to optimize 

perioperative care. Preoperative examinations may be billed by using an appropriate CPT code (e.g., 

new patient, established patient, or consultation). Such non-global preoperative examinations are 

payable if they are medically necessary and meet the documentation and other requirements for the 

service billed. 

D. Preoperative Diagnostic Tests -- Tests performed to determine a patient's perioperative risk and 

optimize perioperative care. Preoperative diagnostic tests are payable if they are medically necessary 

and meet any other applicable requirements. 

5-15 




E. Statutory Basis for Payment 

1. §1862(a)(7) of the Social Security Act (the Act) excludes payment for "routine physical 

checkups." Both physical examinations and diagnostic tests that are performed in the absence of 

signs or symptoms of illness or injury may be denied as a routine physical checkup under 

§1862(a)(7) of the Act. The regulatory provision that further explains this policy is contained in 

42 CFR Part 411.15(a)(1). 

2. §1862(a)(1)(A) of the Act states that no payment will be made for "items or services which are 

not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 

functioning of a malformed body member." Both physical examinations and diagnostic tests 

performed in the absence of signs or symptoms can be denied as unnecessary under 

§1862(a)(1)(A) of the Act. 

3. Through previous program and decision memoranda, Medicare has established a clear hierarchy 

in the application of these two statutory provisions for use in denying payment for physical 

examinations and diagnostic tests. Claims are initially evaluated against the statutory 

requirements of §1862(a)(7) of the Act and, if not denied on that basis, they are evaluated against 

the statutory requirements of §1862 (a)(1)(A). If they meet the statutory requirements of 

§1862(a)(1)(A) of the Act, they are paid. In general, §1862(a)(1)(A) of the Act is to be invoked 

only for denying payment for services that are otherwise covered, and are not otherwise excluded 

from payment, but which are not covered in a particular case because they are not deemed 

"medically reasonable and necessary" when performed in that specific situation. 

F. Applicability of §1862(a)(7) of the Act to Preoperative Services 

1. Preoperative Examinations—For purposes of billing under the Physician Fee Schedule, medical 

preoperative examinations performed by, or at the request of, the attending surgeon do not fall 

within the statutory exclusion articulated in §1862(a)(7) of the Act. These examinations are 

payable if they are medically necessary (i.e., based on a determination of medical necessity under 

§1862(a)(1)(A) of the Act), and meet the documentation requirements of the service billed. 

Determination of the appropriate E/M code is based on the requirements of the specific type and 

level of visit or consultation the physician submits on his claim (e.g., established patient, new 

patient, consultation). 

2. Preoperative Diagnostic Tests—When billing under the Physician Fee Schedule, preoperative 

diagnostic tests performed by, or at the request of, the physician performing preoperative 

examinations, do not fall within the statutory exclusion articulated in §1862)(a)(7) of the Act. 

These diagnostic tests are payable if they are medically necessary (i.e., they may be denied under 

§1862(a)(1)(A)). 

G. ICD-9 Coding Requirements for Preoperative Service - All claims for preoperative medical 

examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be 

accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through 

V72.84). Additional appropriate ICD-9 codes for the condition(s) that prompted surgery and for 

conditions that prompted the preoperative medical evaluation (if any), should also be documented on 

the claim. Other diagnoses and conditions affecting the patient may also be documented on the claim, 

if appropriate. The ICD-9 code appearing in the line item of a preoperative examination or diagnostic 

test must be the code for the appropriate preoperative examination (e.g., V72.81 through V72.84) 

H. Reasonable and Necessary Services -For the purposes of establishing preoperative services as 

reasonable and necessary, all claims are subject to applicable national coverage decisions. In the 

absence of a national coverage decision, reasonable and necessary services are determined by Carrier 

discretion. Establishing reasonable and necessary preoperative medical evaluations is facilitated when 

the ICD-9 code(s) for the condition(s) that prompted surgery, and for the conditions that prompted the 

5-16 




preoperative medical evaluation (if any), are documented as additional diagnoses on the claim. 

[Medicare Carriers Manual, Part 3, Claims Process §15046 – CMS Paper Manual 

Physician Regulatory Issues Team (PRIT) Issue – History and Physicals by Podiatrists 

Issue 

Status 

Podiatrists have asked that Medicare allow them to perform H&Ps on hospital 

inpatients. 

CMS is considering a change to the Hospital Condition of Participation that 

would permit Podiatrists to perform this service. 

August 13, 2004 The Hospital Condition of Participation are now in the final approval process. 

One of 4 PRIT issues which will be resolved in the soon to be released Hospitals 

October 6, 2004 Conditions of Participation. 

The PRIT will announce on this website when the Hospital CoP is released. 

Dec 20, 2004 CMS published a proposed rule - Hospital CoP 3122-P - that addresses this 

issue. 

March 25, 2005 The clearance process is very involved for changes to the Conditions of 

Participation. However, we are confident that the new CoP will be released late 

May 9, 2006 

in 2006 or very early in 2007. 

Date Issue Created 12/01/2003 

Physician Regulatory Issues Team (PRIT) Issue – History and Physicals for Outpatient Surgical 

Procedures 

Issue 

Hospitals have asked if it would be permissible to allow non-credentialed 

physicians to do the History and Physicals. 

Status 

Current interpretive guidelines require that a physician must be credentialed by a 

hospital in order to be able to do the history and physical which is required 

before a patient can have ambulatory surgery at that hospital. We will discuss 

this policy with CMS policy experts and appropriate specialty societies. 

We have discussed this issue with the American College of Surgeons and we 

July 15 

have a meeting about this issue with the American College of Physicians next 

week. 

Surgeons routinely provide focused H&Ps to their surgical patients as part of the 

September 29 preoperative services which are bundled into the payment for the surgery. 

Patients who have significant comorbid conditions may require a preoperative 

visit with an internist or subspecialist in which case that visit would be covered. 

It would be appropriate for the internist to perform a focused H&P and make 

recommendations concerning the management of the patient’s comorbid 

conditions during the preoperative period. 


LESION DESTRUCTION/EXCISION 

Coding the destruction or removal of skin lesions can be one of the most challenging coding processes 

faced by a biller. The anatomical site, number (and size, if necessary) of lesions involved, the type of 

lesion (e.g., skin tag, benign or malignant), and method of removal must be identified to select the proper 

code(s). 

Paring or Cutting 

To report paring or cutting of benign hyperkeratotic lesions (e.g., corn or callus) see codes 11055-11057 

5-17 




Note codes 11055-11057 are reported based on the number of lesions involved. Only one code would be 

used to describe the procedure based on the number of lesions pared or cut. For example, if the physician 

pared three (3) corns. The physician would report 11056. This code is to be used to report two to four 

lesions. 

Removal of Skin Tags 

Regardless of the method of removal (e.g., scissoring, sharp method, ligature strangulation, 

electrosurgical destruction, or combination of treatment modalities including chemical or 

electrocauterization of wound, with or without local anesthesia), codes 11200-11201 are used to report the 

service. 

Note these codes are based on the number of skin tags involved. Code 11201 is an add-on procedure that 

cannot be reported without 11200. Multiple surgical procedures rules do not apply to add-on codes. For 

example, 20 skin tags are removed. 

The service should be reported as: 

11200 1 unit 

11201 1 unit 

Shaving of Epidermal or Dermal Lesions 

According to CPT, Shaving is the sharp removal by transverse incision or horizontal slicing to remove 

epidermal and dermal lesions without a full-thickness dermal excision. This includes local anesthesia, 

chemical, or electrocauterization of the wound. The wound does not require suture closure. 

Physicians sometimes refer to this procedure as a shave biopsy. If the term shave biopsy is used, the coder 

needs to verify if the entire lesion was shaved (11300-11313) or if a piece of tissue was removed to be 

sent for pathology (11100 and 11101). 

The shaving codes (11300-11313) are defined by size and anatomical site. Each lesion removed by shave 

technique is coded separately. Multiple surgical procedure rules apply to these codes. 

Excision Benign Lesions 

Benign excision is defined as full-thickness (through the dermis) removal of lesions of the skin or 

subcutaneous tissue (e.g., cicatricial, fibrous, inflammatory, congenital, cystic lesions, etc.). Simple 

closure is included in the excision code; however, intermediate or complex closure may be reported 

separately for excised diameter greater than 0.5 cm. When both the excision and repair codes are reported, 

multiple surgical procedure rules apply. 

The excision of benign lesion codes (11400-11446) are defined by size (including margins) and 

anatomical site. Each lesion excised is coded separately. Multiple surgical procedure rules apply to these 

codes. 

Excision of Malignant Lesions 

Malignant lesion excision is defined as full-thickness (through the dermis) removal of malignant lesions 

(pathology report available) of the skin or subcutaneous tissue. Closure by suture is required when using 

codes 11600-11646. Simple closure is included in the excision code; however, intermediate or complex 

closure may be reported separately. When both the excision and repair codes are reported, multiple 

surgical procedure rules apply. 

5-18 




The excision of malignant lesion codes (11600-11646) are defined by size (including margins) and 

anatomical site. Each lesion excised is coded separately. Multiple surgical procedure rules apply to these 

codes. 

Destruction 

According to CPT, Destruction means the ablation of benign, premalignant, or malignant tissues by any 

method, with or without curettement, including local anesthesia, and not usually requiring closure. 

Any method includes electrosurgery, cryosurgery, laser, and chemical treatment. Lesions include 

condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (i.e., common, plantar, flat), 

milia, or other benign, premalignant (e.g., actinic keratoses), or malignant lesions. 

Destruction Premalignant Lesions - Coding Change – Reporting Destruction of Benign or Premalignant 

Lesions 

Newby Note: Significant revisions in the descriptions for the following codes require 

adjustments of billing practices for the destruction of lesions. Be sure to update your 

superbill/charge ticket to reflect these changes. 

17000 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), 

premalignant lesions [Emphasis Added] (e.g., actinic keratosis); first lesion 


premalignant lesions [Emphasis Added] (e.g., actinic keratosis); second through 14 lesions each 

(List separately in addition to code for first lesion) 


premalignant lesions [Emphasis Added] (e.g., actinic keratosis); 15 or more lesions 

Please note code 17004 is not an add-on code. If 15 or more lesions are destroyed on the same patient on 

the same day, only code 17004 is reported (codes 17000 and 17003 are bundled). 

Destruction Benign Lesions including Flat Wart, Molluscum Contagiosum, or Milia 

Codes 17110-17111 should be used to report the destruction of benign lesions, flat warts, molluscum 

contagiosum, or milia. 


benign lesions [Emphasis Added] other than skin tags or cutaneous vascular lesions; up to 14 

lesions 


benign lesions [Emphasis Added] other than skin tags or cutaneous vascular lesions; 15 or more 

lesions 

Destructions Malignant Lesions 

Codes 17260-17286 are used to report the destruction of malignant lesions (pathology report available). 

Note codes 17260-17286 are defined by size and anatomical site. Each lesion is coded separately. 

Multiple surgical procedure rules apply to these codes. 

ACTINIC KERATOSIS 

Medicare National Coverage Determinations Manual – Chapter 1, Part 4 - §250.4 - (Rev. 1, 10-01-03) 

CIM 35-101 

Actinic keratoses (AKs), also known as solar keratoses, are common, sun-induced skin lesions that are 

confined to the epidermis and have the potential to become a skin cancer. 

5-19 




Various options exist for treating AKs. Clinicians should select an appropriate treatment based on the 

patient’s medical history, the lesion’s characteristics, and on the patient’s preference for a specific 

treatment. Commonly performed treatments for AKs include cryosurgery with liquid nitrogen, topical 

drug therapy, and curettage. Less commonly performed treatments for AK include dermabrasion, 

excision, chemical peels, laser therapy, and photodynamic therapy (PDT). An alternative approach to 

treating AKs is to observe the lesions over time and remove them only if they exhibit specific clinical 

features suggesting possible transformation to invasive squamous cell carcinoma (SCC). 

Medicare covers the destruction of actinic keratoses without restrictions based on lesion or patient 

characteristics. 

WOUND REPAIR (CLOSURE) - CPT/HCPCS Codes 12001-13300 and G0168 

These series of codes are used to describe laceration repair and, in limited situations, closure from a 

procedure. Wound closure includes repair by sutures, staples, or tissue adhesives (e.g., 2-cyanoacrylate), 

either singly or in combination with each other, or in combination with adhesive strips. Wound closure 

utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code. For 

Medicare claims when a wound is closed solely with tissue adhesive, physicians are instructed to use code 

G0168, wound closure utilizing tissue adhesive only. Repair (closure) of most surgical wounds is 

included in the allowance for the primary surgical procedure. However, for certain procedures, wound 

closure may be separately billed. 

Undermining the wound margins to permit closure is usually not separately billable using the 

intermediate or complex wound repair codes. 

When the wound repair codes 12001-13300 are used for closure of traumatic wounds, the CPT coding 

guidelines should be followed. 

Codes 20100-20103 are used to report exploration and repair of trauma wounds requiring Enlargement, 

extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or 

coagulation of minor subcutaneous and/or muscular blood vessel(s) of the subcutaneous tissue, muscle 

fascia, and/or muscle, not requiring thoracotomy or laparoscopy. 

Bundling Of Repair Codes Into Excision Of Benign Lesion Codes 

Payment for the excision of benign or malignant lesions of skin includes payment for simple repairs. 

Separate payment for simple repairs (CPT codes 12001-12018) will not be made when reported with the 

CPT codes for the excision of benign lesions (11400-11446) or the excision of malignant lesions 

(11600-11646). 

Medicare Bundling 

For Medicare claims, payment for the excision of benign lesions with an excised diameter of 0.5 cm or 

less (CPT 11400, 11420, and 11440) includes payment for simple, intermediate, or complex repairs. In 

other words, separate payment for simple, intermediate, or complex repairs (CPT 12001-12018) will not 

be made when reported with CPT codes 11400, 11420, and 11440. 

Carriers use existing definitions for simple, intermediate, and complex repairs listed in the American 

Medical Association's Physicians’ Current Procedural Terminology (CPT). For Medicare claims, payment 

for the excision of a benign lesion with an excised diameter greater than 0.5 cm or the excision of a 

malignant lesion of any size does not include payment for intermediate or complex repairs. Separate 

payment for medically necessary intermediate repairs (CPT codes 12031-12057) or medically necessary 

5-20 




complex repairs (CPT codes 13100-13152) may be made when reported with CPT codes 11401-11406, 

11421-11426, 11441-11446, and 11600-11646. 

REMOVAL OF CERUMEN 

In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), 

the American Medical Association (AMA) included the following information in the July 2005 issue of 

CPT Assistant. The intent of presenting the material is to provide some typical coding scenarios with 

regard to the appropriate use and application of CPT codes related to earwax removal e.g., 69210. 

These three scenarios represent frequent patient encounters related to the need for earwax removal: 

1. The patient presents to the office for the removal of “earwax” by the nurse via 

irrigation. 

2. The patient presents to the office for the removal of “earwax” by the primary care 

physician via irrigation or lavage. 

3. The patient presents to the office for “earwax” removal as the presenting complaint. 

This is described as impacted cerumen because it completely covers the eardrum and 

the patient has hearing loss. The impacted cerumen is removed by the primary care 

physician or otolaryngologist with magnification provided by an otoscope or 

operating microscope and instruments such as wax curettes, forceps, and suction. 

The AMA states, “A major element in determining whether code 69210 should be 

reported is understanding the definition of impacted cerumen.” According to the AAO- 

HNS, 

If any one or more of the following are present, cerumen should be considered 

“impacted” clinically: 

• Visual considerations: Cerumen impairs exam of clinically significant portions of 

the external auditory canal, tympanic membrane, or middle ear conditions. 

• Qualitative considerations: Extremely hard, dry, irritative cerumen causing 

symptoms such as pain, itching, hearing loss, etc 

• Inflammatory considerations: associated with foul odor, infection, or dermatitis 

• Quantitative considerations: Obstructive, copious cerumen that cannot be 

removed without magnification and multiple instruments requiring physician 

skills.” 

The article also includes: 

Removing wax that is not impacted does not warrant the reporting of CPT code 

69210. Rather, that work would appropriately be captured by an evaluation and 

management (E/M) code regardless of how it is removed. 

If, however, the wax is truly impacted, then its removal should be reported with 

69210 if performed by a physician using at a minimum an otoscope and 

instruments such as wax curettes, or in the case of many otolaryngologists, with 

an operating microscope and suction plus specific ear instruments (e.g., cup 

forceps, right angles). 

Accompanying documentation should indicate the time, effort, and equipment 

required to provide the service. 

5-21 




Add-on code 69990, microsurgical techniques, requiring use of operating 

microscope (List separately in addition to code for primary procedure), should 

not be reported if the operating microscope is used for cerumen removal. In this 

latter instance, however, code 92504 binocular microscopy (separate diagnostic 

procedure), may be reported. 

Therefore, based on this information, Scenarios 1 and 2 above would not be 

reported with code 69210. These scenarios would be captured by the appropriate 

E/M code. 

Scenario 3, however, should be reported with code 69210 because both criteria 

were met; the patient had cerumen impaction and the removal required physician 

work using at least an otoscope and instrumentation rather than simple lavage. 

BURNS, LOCAL TREATMENT 

The following codes are used to report local treatment of burned surface only. 

CPT 

CODE 

STATUS OF 

PROBLEMS 

16000 Initial treatment, first degree burn, when not more than local treatment is required 

16020 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less 

than 5% total body surface area) 

16025 

16030 

Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium 

(e.g., whole face or whole extremity, or 5% to 10% total body surface area) 

Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (e.g., 

more than one extremity, or greater than 10% total body surface area 

SPRAINED FINGER(S) 

The following information was presented during the 2003 CPT Coding Symposium, November 14, 2002. 

Question: What is the correct code for buddy taping fingers, taping one finger to another for 

immobilizing a sprained finger 

Answer: Taping one finger to another for immobilizing a sprained finger is not reported 

separately, as it is considered a part of an Evaluation and Management (E/M) code. 

FRACTURE CARE 

If a physician treats a fracture and is responsible for the total fracture care, the appropriate fracture code 

would be reported based on the treatment provided. 

The fracture/dislocation treatment codes are generally reported by the physician responsible for the initial 

casting/strapping/splinting and follow-up care until the fracture/dislocation is healed. This is considered 

surgical treatment. 

When the physician provides a non-surgical treatment of the fracture/dislocation without the application 

of a brace, splint, or cast or without any follow-up care, the physician should only report the appropriate 

E/M codes based on the type of history, exam, and medical decision making required by the patient. 

5-22 




HEMORRHOIDECTOMY BY SIMPLE LIGATURE 

Billing Excessive Units of Service for CPT 46221 

Recent data analysis and Medical Review findings for CPT 46221 (Hemorrhoidectomy, by simple 

ligature (e.g., rubber band)) indicated a high error rate in the utilization of this code. Reviews revealed 

providers were billing CPT 46221 more than once per session for the same beneficiary. 

When billing CPT 46221, only one unit of service is reported regardless of the number of hemorrhoids 

ligated during the session. The October 1997 CPT Assistant article states "Each session of rubber band 

ligation, regardless of the number of hemorrhoids, is coded once." 

Please review your billing of CPT 46221 to determine any potential overpayments made to your practice. 

If you identify any overpayments, it is your responsibility to perform a voluntary refund to the Medicare 

Program. 

URETHRAL CATHETERIZATION 

Code 5170 describes catheterization of a patient for residual urine. 

Code 51702 describes insertion of Foley catheter for patients with chronic problems, such as 

neurogenic bladder and insertion of catheters in patients in acute retention in the hospital setting. 

Code 51703 describes a complicated insertion (e.g., altered anatomy, fractured catheter/balloon). 

Newby Note: Physicians should continue to use HCPCS code P9612, catheterization for 

collection of specimen, single patient, all places of service, when the patient is catheterized 

for a sterile urine specimen. 

GROUP PRACTICE DEFINED 

Medicare General Information, Eligibility, and Entitlement Chapter 5 §90.4 (Rev. 1, 09-11-02) 

A group practice is a group of two or more physicians and non-physician practitioners legally organized 

in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or 

similar association: 

• In which each physician who is a member of the group provides substantially the full range of 

services which the physician routinely provides (including medical care, consultation, diagnosis, 

or treatment) through the joint use of shared office space, facilities, equipment, and personnel 

• For which substantially all of the services of the physicians who are members of the group are 

provided through the group and are billed in the name of the group and amounts so received are 

treated as receipts of the group 

• In which the overhead expenses of and the income from the practice are distributed in accordance 

with methods previously determined by members of the group 

• Which meets such other standards as the Secretary may impose by regulation to implement 

§1877(h)(4) of the Social Security Act. The group practice definition also applies to health care 

practitioners. 

Physicians in Group Practice 

Medicare Claims Processing Manual Chapter 12 §30.6.5 (Rev. 1, 10-01-03) 

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 

5-23 




physicians should select a level of service representative of the combined visits and submit the 

appropriate code for that level. 

Physicians in the same group practice but who are in different specialties may bill and be paid without 

regard to their membership in the same group. 

EVALUATION AND MANAGEMENT (E/M) SERVICES FURNISHED INCIDENT TO 

PHYSICIAN’S SERVICE BY NONPHYSICIAN PRACTITIONERS 

Medicare Claims Processing Manual Chapter 12 §30.6.4 (Rev. 1, 10-01-03) 

When evaluation and management services are furnished incident to a physician’s service by a 

nonphysician practitioner, the physician may bill the CPT code that describes the evaluation and 

management service furnished. 

When evaluation and management services are furnished incident to a physician’s service by a 

nonphysician employee of the physician, not as part of a physician service, the physician bills code 99211 

for the service. 

A physician is not precluded from billing under the “incident to” provision for services provided by 

employees whose services cannot be paid for directly under the Medicare Program. Employees of the 

physician may provide services incident to the physician’s service, but the physician alone is permitted to 

bill Medicare. 

Services provided by employees as “incident to” are covered when they meet all the requirements for 

incident to and are medically necessary for the individual needs of the patient. 

Split/Shared E/M Service 

Office/Clinic Setting 

In the office/clinic setting when the physician performs the E/M service the service must be reported 

using the physician’s UPIN/PIN. When an E/M service is a shared/split encounter between a physician 

and a non-physician practitioner (NP, PA, CNS, or CNM), the service is considered to have been 

performed “incident to” if the requirements for “incident to” are met and the patient is an established 

patient. If “incident to” requirements are not met for the shared/split E/M service, the service must be 

billed under the NPP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule 

payment. 

Hospital Inpatient/Outpatient/Emergency Department Setting 

When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a 

physician and an NPP from the same group practice and the physician provides any face-to-face portion 

of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's 

UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the 

physician (e.g., even if the physician participated in the service by reviewing the patient’s medical 

record), then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the 

appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim. 

Examples of Shared Visits 

• If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-toface 

visit with the patient on the same day, the physician or the NPP may report the service. 

• In an office setting the NPP performs a portion of an E/M encounter and the physician completes 

the E/M service. If the "incident to" requirements are met, the physician reports the service. If the 

“incident to” requirements are not met, the service must be reported using the NPP’s UPIN/PIN. 

5-24 




Medicare “Incident to Clarification” 

Medicare Benefit Policy Manual - Chapter 15 – §60.1 - (Rev. 1, 10-01-03) - B3-2050.1 

Incident to a physician’s professional services means that the services or supplies are furnished as an 

integral, although incidental, part of the physician’s personal professional services in the course of 

diagnosis or treatment of an injury or illness. 

Where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and 

includes the charges for their services in his/her own bills, the services of such personnel are considered 

incident to the physician’s service if there is a physician’s service rendered to which the services of such 

personnel are an incidental part and there is direct supervision by the physician. 

This does not mean, however, that to be considered incident to, each occasion of service by auxiliary 

personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a 

personal professional service by the physician. Such a service or supply could be considered to be 

incident to when furnished during a course of treatment where the physician performs an initial service 

[Emphasis added] and subsequent services of a frequency which reflect his/her active participation in and 

management of the course of treatment. (However, the direct supervision requirement must still be met 

with respect to every nonphysician service.) 

Direct supervision in the office setting does not mean that the physician must be present in the same room 

with his or her aide. However, the physician must be present in the office suite and immediately available 

to provide assistance and direction throughout the time the aide is performing services. 

If auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or in an 

institution (other than hospital or SNF), their services are covered incident to a physician’s service only if 

there is direct supervision by the physician. For example, if a nurse accompanied the physician on house 

calls and administered an injection, the nurse’s services are covered. If the same nurse made the calls 

alone and administered the injection, the services are not covered (even when billed by the physician) 

since the physician is not providing direct supervision. Services provided by auxiliary personnel in an 

institution (e.g., nursing, or convalescent home) present a special problem in determining whether direct 

physician supervision exists. The availability of the physician by telephone and the presence of the 

physician somewhere in the institution does not constitute direct supervision. For hospital patients and for 

SNF patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the services of 

physician-employed auxiliary personnel as services incident to physicians’ services under §1861(s)(2)(A) 

of the Act. Such services can be covered only under the hospital or SNF benefit and payment for such 

services can be made to only the hospital or SNF by a Medicare Intermediary. 

Services Of Nonphysician Personnel Furnished Incident To Physician’s Services 

Medicare Benefit Policy Manual - Chapter 15 – §60.2 - (Rev. 1, 10-01-03) - B3-2050.2 

In addition to coverage being available for the services of such auxiliary personnel as nurses, technicians, 

and therapists when furnished incident to the professional services of a physician (as discussed in §60.1), 

a physician may also have the services of certain nonphysician practitioners covered as services incident 

to a physician’s professional services. These nonphysician practitioners, who are being licensed by the 

States under various programs to assist or act in the place of the physician, include, for example, certified 

nurse midwives, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, 

and clinical nurse specialists. 

Services performed by these nonphysician practitioners incident to a physician’s professional services 

include not only services ordinarily rendered by a physician’s office staff person (e.g., medical services 

such as taking blood pressures and temperatures, giving injections, and changing dressings) but also 

5-25 




services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, 

reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition. 

Nonetheless, in order for services of a nonphysician practitioner to be covered as incident to the services 

of a physician, the services must meet all of the requirements for coverage specified in §§60 through 60.1. 

For example, the services must be an integral, although incidental, part of the physician’s personal 

professional services, and they must be performed under the physician’s direct supervision. 

A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under 

State law to perform a specific medical procedure and may be able to perform the procedure without 

physician supervision and have the service separately covered and paid for by Medicare as a physician 

assistant’s or nurse practitioner’s service. However, in order to have that same service covered as incident 

to the services of a physician, it must be performed under the direct supervision of the physician as an 

integral part of the physician’s personal in-office service. 

As explained in §60.1, this does not mean that each occasion of an incidental service performed by a 

nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It 

does mean that there must have been a direct, personal, professional service furnished by the physician to 

initiate the course of treatment of which the service being performed by the nonphysician practitioner is 

an incidental part, and there must be subsequent services by the physician of a frequency that reflects the 

physician’s continuing active participation in and management of the course of treatment. In addition, the 

physician must be physically present in the same office suite and be immediately available to render 

assistance if that becomes necessary. 

Incident-To Services on Form CMS-1500 

Medicare Claims Processing Manual – Chapter 26 - §10.4 - Items 14-33 - Provider of Service or 

Supplier Information = (Rev. 1215, Issued: 03-30-07, Effective: 04-01-07, Implementation: 04-30-07) 

Item 17 When a service is incident to the service of a physician or non-physician practitioner, the 

name of the physician or non-physician practitioner who performs the initial service and 

orders the non-physician service must appear in item 17; 

Item 17a Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering 

physician listed in item 17. Under Medicare’s NPI contingency plan, the UPIN may be 

reported on the Form CMS-1500 and MUST be reported if an NPI is not available. 

Item 17b 

Item 24J 

Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available. 

During Medicare’s NPI contingency plan, enter the rendering provider’s PIN in the shaded 

portion. In the case of a service provided incident to the service of a physician or nonphysician 

practitioner, when the person who ordered the service is not supervising, enter the 

PIN of the supervisor in the shaded portion. 

Enter the rendering provider’s NPI number in the lower portion. In the case of a service 

provided incident to the service of a physician or non-physician practitioner, when the person 

who ordered the service is not supervising, enter the NPI of the supervisor in the lower 

portion. 

OFFICE/OUTPATIENT VISITS – CPT CODES 99201-99215 

A. Definition of New Patient for Selection of E/M Visit Code 

Interpret 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 

5-26 




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. 

Newby Note: 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 physician should select a level of service 

representative of the combined visits and submit the appropriate code for that level. 

Physicians in the same group practice but who are in different specialties may bill and be 

paid without regard to their membership in the same group. 

There is no difference if the group physicians are located in the same or different 

buildings. Therefore, even though a physician may be located on another campus, if a 

patient previously cared for by the same specialty physician in the same group within the 

previous three years is seen by a group physician of the same specialty at a setting apart 

from where his/her care is generally rendered and where his/her medical records may be 

located, for billing purposes, that patient remains an established patient for that same 

group, same specialty physician. It is the group’s responsibility to coordinate record 

keeping when different locations are involved. 

Changing Group Practices 

Dr. Smith leaves his/her practice in Indianapolis to join a new practice in Carmel. If Dr. 

Smith, or another physician of the same specialty in the Carmel practice, has not provided 

any professional services to that patient within the past three years, then Dr. Smith would 

consider the patient a new patient. If Dr. Smith has rendered professional services to the 

patient in either the Indianapolis or Carmel practice within the past three years, the 

patient is considered established to Dr. Smith. If Dr. Smith saw the patient in Indianapolis, 

but one of the Carmel physicians sees the patient, the patient would be considered new. 

B. Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems 

As for all other E/M services except where specifically noted, Carriers may not pay two E/M office visits 

billed by a physician (or physician of the same specialty from the same group practice) for the same 

beneficiary on the same day unless the physician documents that the visits were for unrelated problems in 

the office or outpatient setting which could not be provided during the same encounter (e.g., office visit 

for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain 

following an accident). 

C. Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility 

Carriers may not pay a physician for an emergency department visit or an office visit and a 

comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided 

in sites other than the nursing facility into the initial nursing facility care code when performed on the 

same date as the nursing facility admission by the same physician. 

D. Drug Administration Services and E/M Visits Billed on Same Day of Service 

Carriers must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug 

administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 

1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, 

November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). 

Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets 

a higher complexity level than CPT code 99211) is performed, in addition to one of these drug 

5-27 




administration services, the appropriate E/M CPT code should be reported with modifier -25. 

Documentation should support the level of E/M service billed. For an E/M service provided on the same 

day, a different diagnosis is not required. 

99211 Most Abused Code 

Nationwide, 99211 is one of the most abused codes for usage. Code 99211 describes a service provided 

for minimal problems that may not require the presence of a physician, but does require the presence of a 

patient. As stated previously, this code cannot be billed if only an injection is given, without documented 

pertinent questioning or instructions. It cannot be billed for: 

• telephone calls, 

• venipunctures, 

• prescription renewals to a pharmacy, 

• telephone calls for a patient to reschedule an appointment, and 

• telephone calls with the results of laboratory testing. 

Billing 99211 is not allowed for every patient who enters the office for a minimal service and receives an 

unnecessary pulse, temperature, or blood pressure recording. 

Prothrombin Time and Evaluation of Patient Anti-Coagulation Status - CPT Code 99211 

The following was developed from consultation among Medicare Part B Contractor Medical Directors 

and review of the CMS Frequently Asked Questions Web site. The CPT code description for 99211 

follows: 

Office or other outpatient visit for the evaluation and management of an established patient that 

may not require the presence of a physician. Usually, the presenting problem(s) are minimal. 

Typically, five minutes are spent performing or supervising these services. 

When a face-to-face medication management is provided by qualified office staff on the same date of the 

laboratory test, the physician may bill CPT code 99211 if the services are medically necessary and 

constitute a distinct, separately identifiable evaluation and management (E/M) service that is consistent 

with the criteria for a low-level office visit. The following describes adequate documentation for CPT 

code 99211 when billed for an evaluation of a chronically anti-coagulated patient for whom a 

prothrombin time has been drawn and determined. 

Reason for the visit - A physician visit is not routinely necessary in order to draw blood for prothrombin 

time or other laboratory tests. Therefore, the documentation for 99211 or any other E/M code in this 

circumstance must demonstrate a need for clinical evaluation and management. In this case, services that 

would serve to demonstrate that evaluation and management were performed include evaluation of 

significant new symptoms (such as excessive bruising or hemorrhage). Alternatively, for patients who 

have no new clinical concerns, demonstrating how the relevant laboratory information obtained was used 

to modify therapy will document that a separately payable E/M service has been performed. 

• Current medications listed (with notation of level of compliance) 

• Indication of physician’s evaluation of the information about signs/symptoms and laboratory test 

result and his or her management recommendation 

• Identity and credentials of provider(s) as listed in text above 

If the patient does not have any new symptoms or requires a change in the dosage of his/her medication, 

the physician cannot report 99211. 

5-28 




HOSPITAL OBSERVATION SERVICES – CPT CODES 99217-99220 

Medicare Claims Processing Manual Chapter 12 §30.6.8 (Codes 99217 99220) (Rev. 1, 10-01-03) B3- 

15504 

A. Who May Bill Initial Observation Care 

Carriers pay for initial observation care billed by only the physician who admitted the patient to hospital 

observation and was responsible for the patient during his/her stay in observation. A physician who does 

not have inpatient admitting privileges but who is authorized to admit a patient to observation status may 

bill these codes. 

For a physician to bill the initial observation care codes, there must be a medical observation record for 

the patient which contains dated and timed physician’s admitting orders regarding the care the patient is 

to receive while in observation, nursing notes, and progress notes prepared by the physician while the 

patient was in observation status. This record must be in addition to any record prepared as a result of an 

emergency department or outpatient clinic encounter. 

Payment for an initial observation care code is for all the care rendered by the admitting physician on the 

date the patient was admitted to observation. All other physicians who see the patient while he or she is in 

observation must bill the office and other outpatient service codes or outpatient consultation codes as 

appropriate when they provide services to the patient. 

For example, if an internist admits a patient to observation and asks an allergist for a consultation on the 

patient’s condition, only the internist may bill the initial observation care code. The allergist must bill 

using the outpatient consultation code that best represents the services he or she provided. The allergist 

cannot bill an inpatient consultation since the patient was not a hospital inpatient. 

B. Physician Billing for Observation Care Following Admission to Observation 

If the patient is discharged on the same date as admission to observation, Carriers pay only the initial 

observation care code because that code represents a full day of care. 

If the patient remains in observation after the first date following the admission to observation, it is 

expected that the patient would be discharged on that second calendar date. The physician bills CPT code 

99217 for observation care discharge services provided on the second date. 

In the rare circumstance when a patient is held in observation status for more than two calendar dates, the 

physician must bill subsequent services furnished before the date of discharge using the outpatient/office 

visit codes. The physician may not use the subsequent hospital care codes since the patient is not an 

inpatient of the hospital. 

C. Admission to Inpatient Status from Observation 

If the same physician who admitted a patient to observation status also admits the patient to inpatient 

status from observation before the end of the date on which the patient was admitted to observation, pay 

only an initial hospital visit for the evaluation and management services provided on that date. Medicare 

payment for the initial hospital visit includes all services provided to the patient on the date of admission 

by that physician, regardless of the site of service. The physician may not bill an initial observation care 

code for services on the date that he or she admits the patient to inpatient status. If the patient is admitted 

to inpatient status from observation subsequent to the date of admission to observation, the physician 

must bill an initial hospital visit for the services provided on that date. The physician may not bill the 

hospital observation discharge management code (code 99217) or an outpatient/office visit for the care 

provided in observation on the date of admission to inpatient status. 

5-29 




OBSERVATION OR INPATIENT CARE SERVICES – INCLUDING ADMISSION AND 

DISCHARGE SERVICES - CPT CODES 99234-99236 

This series of codes is used to report observation or inpatient hospital care services provided to patients 

admitted and discharged on the same date of service. In order to use these codes for a Medicare patient, 

the patient must have been an inpatient or an observation care patient for a minimum of eight (8) hours on 

the same calendar date. 

When observation status or initial inpatient hospital care is initiated in the course of an encounter in 

another site of service (e.g., hospital emergency department, physician’s office, nursing facility) all 

evaluation and management services provided by the supervising physician in conjunction with initiating 

observation status are considered part of the initial observation care or initial inpatient hospital care when 

performed on the same date. The level of service should include the services related to the admission 

provided in the other sites-of-service as well as in the observation setting when provided by the same 

physician. 

Newby Note: To use codes 99234-99236, the physician must clearly indicate in the 

patient’s medical record the number of hours the patient was in observation or inpatient 

status. 

For patients admitted to observation or inpatient care for less than eight (8) hours or discharged on a 

different date, see codes 99218-99220 and 99217, or 99221-99223 and 99238-99239. 

INPATIENT HOSPITAL VISITS – CPT CODES 99221-99239 

Medicare Claims Processing Manual Chapter 12 §30.6.9 General (Codes 99221-99239) (Rev. 1, 10-01- 

03) B3-15505-15505.2 

A. Hospital Visit and Critical Care on Same Day 

If critical care is required upon the patient’s presentation to the emergency department, only critical care 

codes 99291-99292 may be reported. Emergency department codes will not be paid for the same day. If 

there is a hospital or office/outpatient evaluation and management service furnished early in the day and 

at that time the patient does not require critical care, but the patient requires critical care later in the day, 

both critical care and the evaluation and management service may be paid. 

Physicians must submit supporting documentation when critical care is billed on the same day as other 

evaluation and management services. 

B. Two Hospital Visits Same Day 

Carriers pay a physician for only one hospital visit per day for the same patient, whether the problems 

seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase 

per day which means that the code and the payment established for the code represent all services 

provided on that date. The physician should select a code that reflects all services provided during the 

date of the service. 

C. Hospital Visits Same Day But by Different Physicians 

In a hospital inpatient situation involving one physician covering for another, if physician A sees the 

patient in the morning and physician B, who is covering for A, sees the same patient in the evening, 

Carriers do not pay physician B for the second visit. The hospital visit descriptors include the phrase per 

day meaning care for the day. 

5-30 




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. 

D. Visits to Patients in Swing Beds 

If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. 

If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes 

apply. 

Payment for Initial Hospital Care Services 

Medicare Claims Processing Manual Chapter 12 §30.6.9.1 (Codes 99221-99223) (Rev. 1, 10-01-03) 

A. Initial Hospital Care from Emergency Room 

Carriers pay for an initial hospital care service or an initial inpatient consultation if a physician sees 

his/her patient in the emergency room and decides to admit the person to the hospital. They do not pay for 

both E/M services. Also, they do not pay for an emergency department visit by the same physician on the 

same date of service. 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 that admission are considered part of the initial hospital care when performed on the 

same date as the admission. 

B. Initial Hospital Care on Day Following Visit 

Carriers pay 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. 

C. Initial Hospital Care and Discharge on Same Day 

Carriers pay only the initial hospital care code when a patient is admitted as an inpatient and discharged 

on the same day. They do not pay the hospital discharge management code on the date of admission. 

Newby Note: If the patient is admitted and discharged on the same date of service and the 

patient has been an inpatient for eight (8) or more hours, the physician may use code 

99234-99236. 

D. Physician Services Involving Transfer From One Hospital to Another; Transfer Within Facility to 

Prospective Payment System (PPS) Exempt Unit of Hospital; Transfer From One Facility to Another 

Separate Entity Under Same Ownership and/or Part of Same Complex; or Transfer From One 

Department to Another Within Single Facility 

Physicians may bill both the hospital discharge management code and an initial hospital care code when 

the discharge and admission do not occur on the same day if the transfer is between: 

• Different hospitals; 

• Different facilities under common ownership which do not have merged records; or 

• Between the acute care hospital and a PPS exempt unit within the same hospital when there are 

no merged records. 

In all other transfer circumstances, the physician should bill only the appropriate level of subsequent 

hospital care for the date of transfer. 

E. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive 

When a physician performs a visit or consultation that meets the definition of a Level 5 office visit or 

consultation several days prior to an admission and on the day of admission performs less than a 

comprehensive history and physical, he or she should report the office visit or consultation that reflects 

5-31 




the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the 

initial hospital admission. Carriers pay the office visit as billed and the Level 1 initial hospital care code. 

F. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same 

Admission 

Physicians use the initial hospital care codes (codes 99221-99223) to report the first hospital inpatient 

encounter with the patient when he or she is the admitting physician. 

Carriers consider only one M.D. or D.O. to be the admitting physician and permit only the admitting 

physician to use the initial hospital care codes. Physicians that participate in the care of a patient but are 

not the admitting physician of record should bill the inpatient evaluation and management services codes 

that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient 

consultation). 

G. Initial Hospital Care and Nursing Facility Visit on Same Day 

Carriers pay only the initial hospital care code if the patient is admitted to a hospital following a nursing 

facility visit on the same date by the same physician. Payment for the initial hospital care service includes 

all work performed by the physician in all sites of service on that date. 

Subsequent Hospital Visit and Hospital Discharge Management 

Medicare Claims Processing Manual Chapter 12 §30.6.9.2 (Codes 99231-99239) (Rev. 1, 10-01-03) 

A. Subsequent Hospital Visit and Discharge Management on Same Day 

Carriers only pay the hospital discharge management code on the day of discharge (unless it is also the 

day of admission, in which case, the admission service and not the discharge management service is 

billed). Carriers do not pay both a subsequent hospital visit in addition to hospital discharge day 

management service on the same day by the same physician. 

B. Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission 

Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day 

Carriers pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility 

admission code when they are billed by the same physician with the same date of service. 

Face-to-Face Visit Required for Discharge Services 

All E/M services except where specifically stated (e.g., care plan oversight which is a monthly summary) 

require a face-to-face interaction between the physician and the patient. The discharge service is a face-toface 

E/M service. 

Carriers monitoring for the time period April 2004 through March 2005, the date of service (DOS) of 

seven (7) to fifteen (15) percent of the discharge service codes (99238, 99239, 99315, and 99316) 

submitted were the same as the date of death of the patient. 

CMS provided the following information regarding the use of time-based codes: 

The discharge day management service by definition does not have the elements of history, 

physical examination, and medical decision-making, as many of the other E/M codes have. The 

provider uses this final visit as appropriate, for a final examination, discussion of problems, 

instructions, and follow-up. A provider may choose to bill a subsequent hospital visit service code 

instead of a discharge service code. The provider is not required to bill a discharge day 

management service. 

The discharge day management service is a time-based service. In order to support services that 

require greater than 30 minutes (codes 99239 and 99316) the total time spent must be 

5-32 




documented. If the time is not documented, payment is allowed for the lower level services 

(99238 and 99315). 

A discharge day management service can be split/shared between the nonphysician practitioner 

(NPP) and physician. When the service is shared between a physician and an NPP from the same 

group practice and the physician provides any face-to-face portion of the E/M encounter with the 

patient, the service may be billed under either the physician’s or the NPP’s UPIN/PIN number. 

However, if there was no face-to-face encounter between the patient and the physician (e.g., even 

if the physician participated in the service by reviewing the patient’s medical record), the service 

must be billed under the NPP’s rendering provider number (PIN). 

Medicare will pay for pronouncement of death as long as the provider actually does the 

pronouncement face-to-face with the deceased patient (not over the telephone). There must be 

documentation supporting a face-to-face encounter when billing a discharge service on the date of 

death. If the provider does not see the patient prior to the time of death or make the 

pronouncement of death face-to-face, no E/M service may be billed for that date of service. 

Medicare Certified Swing Bed Hospital Services 

MLN Matters Number: SE0606 

Under the Social Security Act (§1883(a)(1), [42 U.S.C. 1395tt]), any hospital that has an agreement under 

§1866 may enter into an agreement with CMS in which its inpatient hospital facilities may be used for 

furnishing types of service that, if furnished in a Skilled Nursing Facility (SNF), would constitute 

extended care services (subject to §1883(b)). Such a hospital is known as a swing bed hospital. 

Services Covered in a Medicare Certified Swing Bed 

Under the Social Security Act, Section 1883(a)(1), payment for swing bed services will be made only for 

services for which payment would be made as post-hospital extended care services if those services had 

been furnished by an SNF 

CONSULTATIONS – CPT CODES 99241-99255 

Medicare Claims Processing Manual – Chapter 12 §30.6.10 (Codes 99241 99275) (Rev. 1, 10-01-03) B3- 

15506 (Rev. 782, Issued 12-16-05 Effective 01-01-06 Implementation 01-17-06) 

A. Consultation Services versus Other Evaluation and Management (E/M) Visits 

Carriers pay for a reasonable and medically necessary consultation service when all of the following 

criteria for the use of a consultation code are met: 

• Specifically, a consultation service is distinguished from other evaluation and management (E/M) 

visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose 

opinion or advice regarding evaluation and/or management of a specific problem is requested by 

another physician or other appropriate source. The qualified NPP may perform consultation 

services within the scope of practice and licensure requirements for NPPs in the State in which 

he/she practices. Applicable collaboration and general supervision rules apply as well as billing 

rules; 

• A request for a consultation from an appropriate source and the need for consultation (i.e., the 

reason for a consultation service) shall be documented by the consultant in the patient’s medical 

record and included in the requesting physician or qualified NPP’s plan of care in the patient’s 

medical record; and 

• After the consultation is provided, the consultant shall prepare a written report of his/her findings 

and recommendations, which shall be provided to the referring physician. 

5-33 




The intent of a consultation service is that a physician or qualified NPP or other appropriate source is 

asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, 

or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific 

medical area beyond the requesting professional’s knowledge. Consultations may be billed based on time 

if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter 

between the physician or qualified NPP and the patient. The preceding requirements (request, evaluation 

(or counseling/coordination) and written report) shall also be met when the consultation is based on time 

for counseling/coordination. 

A consultation shall not be performed as a split/shared E/M visit. 

B. Consultation Followed by Treatment 

A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial 

consultation service or subsequent visit. Ongoing management, following the initial consultation service 

by the consultant physician, shall not be reported with consultation service codes. These services shall be 

reported as subsequent visits for the appropriate place of service and level of service. Payment for a 

consultation service shall be made regardless of treatment initiation unless a transfer of care occurs. 

Transfer of Care 

A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified 

NPP take over the responsibility for managing the patients’ complete care for the condition and does not 

expect to continue treating or caring for the patient for that condition. 

When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or 

advice to personally treat this patient and is not expecting to continue treating the patient for the 

condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to 

his/her service, in the patient’s medical record or plan of care. 

In a transfer of care, the receiving physician or qualified NPP would report the appropriate new or 

established patient visit code according to the place of service and level of service performed and shall 

not report a consultation service. 

C. Initial and Follow-Up Consultation Services 

Initial Consultation Service 

In the hospital setting, the consulting physician or qualified NPP shall use the appropriate Initial Inpatient 

Consultation codes (99251 – 99255) for the initial consultation service. In the nursing facility setting, the 

consulting physician or qualified NPP shall use the appropriate Initial Inpatient Consultation codes 

(99251 – 99255) for the initial consultation service. The Initial Inpatient Consultation may be reported 

only once per consultant per patient per facility admission. 

In the office or other outpatient setting, the consulting physician, or qualified NPP shall use the 

appropriate Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) 

for the initial consultation service. 

If an additional request for an opinion or advice, regarding the same or a new problem with the same 

patient, is received from the same or another physician or qualified NPP and documented in the medical 

record, the Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) 

may be used again. However, if the consultant continues to care for the patient for the original condition 

following his/her initial consultation, repeat consultation services shall not be reported by this physician 

or qualified NPP during his/her ongoing management of this condition. 

5-34 




Follow-Up Consultation Service 

Effective January 1, 2006, the follow-up inpatient consultation codes (99261 – 99263) are deleted. 

In the hospital setting, following the initial consultation service, the Subsequent Hospital Care codes 

(99231 – 99233) shall be reported for additional follow-up visits. 

In the nursing facility setting, following the initial consultation service, the Subsequent Nursing Facility 

(NF) Care codes (new CPT codes 99307 – 99310) shall be reported for additional follow-up visits. 

Effective January 1, 2006, CPT codes 99311 – 99313 are deleted and not valid for Subsequent NF visits. 

In the office or other outpatient setting, following the initial consultation service, the Office or Other 

Outpatient Established Patient codes (99212 – 99215) shall be reported for additional follow-up visits. 

The CPT code 99211 shall not be reported as a consultation service. The CPT code 99211 is not included 

by Medicare for a consultation service since this service typically does not require the presence of a 

physician or qualified NPP and would not meet the consultation service criteria. 

D. Second Opinion E/M Service Requests 

Effective January 1, 2006, the Confirmatory Consultation codes (99271 – 99275) are deleted. 

A second opinion E/M service is a request by the patient and/or family or mandated (e.g., by a third-party 

payer) and is not requested by a physician or qualified NPP. A consultation service requested by a 

physician, qualified NPP or other appropriate source that meets the requirements stated in Section A shall 

be reported using the initial consultation service codes as discussed in Section C. A written report is not 

required by Medicare to be sent to a physician when an evaluation for a second opinion has been 

requested by the patient and/or family. 

A second opinion, for Medicare purposes, is generally performed as a request for a second or third 

opinion of a previously recommended medical treatment or surgical procedure. A second opinion E/M 

service initiated by a patient and/or family is not reported using the consultation codes. 

In both the inpatient hospital setting and the NF setting, a request for a second opinion would be made 

through the attending physician or physician of record. If an initial consultation is requested of another 

physician or qualified NPP by the attending physician and meets the requirements for a consultation 

service (as identified in Section A) then the appropriate Initial Inpatient Consultation code shall be 

reported by the consultant. If the service does not meet the consultation requirements, then the E/M 

service shall be reported using the Subsequent Hospital Care codes (99231 – 99233) in the inpatient 

hospital setting and the Subsequent NF Care codes (99307 – 99310) in the NF setting. 

A second opinion E/M service performed in the office or other outpatient setting shall be reported using 

the Office or Other Outpatient new patient codes (99201 – 99205) for a new patient and established 

patient codes (99212 – 99215) for an established patient, as appropriate. The 3 year rule regarding “new 

patient” status applies. Any medically necessary follow-up visits shall be reported using the appropriate 

subsequent visit/established patient E/M visit codes. 

The CPT modifier -32 (Mandated Services) is not recognized as a payment modifier in Medicare. A 

second opinion evaluation service to satisfy a requirement for a third party payer is not a covered service 

in Medicare. 

E. Consultations Requested by Members of Same Group 

Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a 

consultation from another physician in the same group practice when the consulting physician or qualified 

5-35 




NPP has expertise in a specific medical area beyond the requesting professional’s knowledge. A 

consultation service shall not be reported on every patient as a routine practice between physicians and 

qualified NPPs within a group practice setting. 

F. Documentation for Consultation Services 

Consultation Request 

• A written request for a consultation from an appropriate source and the need for a consultation 

must be documented in the patient’s medical record. The initial request may be a verbal 

interaction between the requesting physician and the consulting physician; however, the verbal 

conversation shall be documented in the patient’s medical record, indicating a request for a 

consultation service was made by the requesting physician or qualified NPP. 

• The reason for the consultation service shall be documented by the consultant (physician or 

qualified NPP) in the patient’s medical record and included in the requesting physician or 

qualified NPP’s plan of care. The consultation service request may be written on a physician 

order form by the requestor in a shared medical record. 

Consultation Report 

• A written report shall be furnished to the requesting physician or qualified NPP. 

In an emergency department or an inpatient or outpatient setting in which the medical record is shared 

between the referring physician or qualified NPP and the consultant, the request may be documented as 

part of a plan written in the requesting physician or qualified NPP’s progress note, an order in the medical 

record, or a specific written request for the consultation. In these settings, the report may consist of an 

appropriate entry in the common medical record. 

In an office setting, the documentation requirement may be met by a specific written request for the 

consultation from the requesting physician or qualified NPP or if the consultant’s records show a specific 

reference to the request. In this setting, the consultation report is a separate document communicated to 

the requesting physician or qualified NPP. 

In a large group practice, e.g., an academic department or a large multi-specialty group, in which there is 

often a shared medical record, it is acceptable to include the consultant’s report in the medical record 

documentation and not require a separate letter from the consulting physician or qualified NPP to the 

requesting physician or qualified NPP. The written request and the consultation evaluation, findings and 

recommendations shall be available in the consultation report. 

G. Consultation for Preoperative Clearance 

Preoperative consultations are payable for new or established patients performed by any physician or 

qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting 

the consultation codes are met and the service is medically necessary and not routine screening. 

H. Postoperative Care by Physician Who Did Preoperative Clearance Consultation 

If subsequent to the completion of a preoperative consultation in the office or hospital, the consultant 

assumes responsibility for the management of a portion or all of the patient’s condition(s) during the 

postoperative period, the consultation codes should not be used postoperatively. In the hospital setting, 

the physician or qualified NPP who has performed a preoperative consultation and assumes responsibility 

for the management of a portion or all of the patient’s condition(s) during the postoperative period should 

use the appropriate subsequent hospital care codes to bill for the concurrent care he or she is providing. In 

the office setting, the appropriate established patient visit codes should be used during the postoperative 

period. 

5-36 




A physician (primary care or specialist) or qualified NPP who performs a postoperative evaluation of a 

new or established patient at the request of the surgeon may bill the appropriate consultation code for 

evaluation and management services furnished during the postoperative period following surgery when all 

of the criteria for the use of the consultation codes are met and that same physician has not already 

performed a preoperative consultation. 

I. Surgeon’s Request That Another Physician Participate In Postoperative Care 

If the surgeon asks a physician or qualified NPP who had been treating the patient preoperatively or who 

had not seen the patient for a preoperative consultation to take responsibility for the management of an 

aspect of the patient’s condition during the postoperative period, the physician or qualified NPP may not 

bill a consultation because the surgeon is not asking the physician or qualified NPP’s opinion or advice 

for the surgeon’s use in treating the patient. The physician or qualified NPP’s services would constitute 

concurrent care and should be billed using the appropriate subsequent hospital care codes in the hospital 

inpatient setting, subsequent NF care codes in the SNF/NF setting or the appropriate office or other 

outpatient visit codes in the office or outpatient settings. 

Physicians Regulatory Issues Team (PRIT) – Definition of a Consultation 

Issue 

The Indiana State Medical Association and others feel confused by the 

definition of Transfer of Care found in Transmittal 788. 

Status 

The PRIT is facilitating dialog between CMS staff, providers, and 

carrier staff to clarify this definition. 

July 10 

August 28 

October 23, 2006 

January 11, 2007 

The PRIT has been contacted by the Infectious Disease Society of 

America, the American College of Physicians, the American Medical 

Association and several other specialty societies about clarifying the 

definition of a consult in transmittal 788. We are working with them to 

address the issue. 

This issue was discussed at the August 28 2006 meeting of the 

Practicing Physician's Advisory Council. 

A letter signed by 51 medical associations and societies was sent to the 

CMS administration requesting clarification on this issue. 

There are instances of a “shared care” scenario which do meet the 

intent of a consultation. For example, a primary care physician consults 

with a specialist for a specific problem. The specialist evaluates the 

patient and continues to manage that aspect of the patient's care while 

the primary care physician continues to manage the overall patient care 

guided by the information from the specialist. 


EMERGENCY DEPARTMENT VISITS – CPT CODES 99281-99285 

Medicare Claims Processing Manual Chapter 12 §30.6.11 (Codes 99281-99288) (Rev. 1, 10-01-03) B3- 

15507 

A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department 

Any physician seeing a patient registered in the emergency department may use emergency department 

visit codes (for services matching the code description). It is not required that the physician be assigned to 

the emergency department. 

5-37 




B. Use of Emergency Department Codes in Office 

Emergency department coding is not appropriate if the site of service is an office or outpatient setting or 

any sight of service other than an emergency department. The emergency department codes should only 

be used if the patient is seen in the emergency department and the services described by the HCPCS code 

definition are provided. The emergency department is defined as an organized hospital-based facility for 

the provision of unscheduled or episodic services to patients who present for immediate medical attention. 

C. Use of Emergency Department Codes to Bill Nonemergency Services 

Services in the emergency department may not be emergencies. However, the codes (99281-99288) are 

payable if the described services are provided. 

However, if the physician asks the patient to meet him or her in the emergency department as an 

alternative to the physician’s office and the patient is not registered as a patient in the emergency 

department, the physician should bill the appropriate office/outpatient visit codes. Normally a lower level 

of emergency department code would be reported for a nonemergency condition. 

D. Emergency Department or Office/Outpatient Visits on Same Day as Nursing Facility Admission 

Emergency department visit provided on the same day as a comprehensive nursing facility assessment are 

not paid. Payment for evaluation and management services on the same date provided in sites other than 

the nursing facility are included in the payment for initial nursing facility care when performed on the 

same date as the nursing facility admission. 

E. Physician Billing for Emergency Department Services Provided to Patient by Both Patient’s Personal 

Physician and Emergency Department Physician 

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 physicians 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. The patient’s personal physician would not bill a 

consultation because he or she is not providing information to the emergency department 

physician for his or her use in treating the patient. 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. 

NURSING FACILITY VISITS – CPT CODES 99304-99316 

Initial Nursing Facility Care 

Codes 99304-99306 are selected based on the type of history, exam, and medical decision making based 

which will be based on the patient’s problem(s) requiring admission to the facility. Typical times have not 

been established. CPT provides guidance for selecting the appropriate level of admission by giving the 

5-38 




typical severity of the problem(s) requiring admission. These codes should be reported by the admitting 

physician responsible for the care of the patient during the inpatient stay. 

Annual Nursing Facility Services 

Code 99318 is used to describe the annual nursing facility assessment. This code must include a detailed 

interval history, a comprehensive examination, and medical decision making that is of low to moderate 

complexity. These patients are usually stable, recovering, or improving. Physicians should not report 

99318 on the same day as subsequent nursing facility codes 99307-99310. 

Subsequent Nursing Facility Care 

Codes 99307-99310 are selected based on the type of history, exam, and medical decision making which 

will be based on the patient’s presenting problem(s). Typical times have not been established. CPT 

provides guidance for selecting the appropriate level of admission by the patient’s status, e.g., stable, 

inadequate response to therapy, new problem, etc. 

Nursing Facility Discharge 

Discharge day management services are coded 99315 or 99316. The codes are selected based on the 

amount of time spent for the final discharge from the nursing facility. 

Medicare Guidelines for Nursing Facility Coding 

Medicare Claims Processing Manual Chapter 12 §30.6.13 (Rev. 1, 10-01-03) B3-15509-15509.1 (Rev. 

808 Implementation No later than 01-23-06) 

A. Visits to Perform the Initial Comprehensive Assessment and Annual Assessments 

The distinction made between the delegation of physician visits and tasks in a skilled nursing facility 

(SNF) and in a nursing facility (NF) is based on the Medicare Statute. §1819 (b) (6) (A) of the Social 

Security Act (the Act) governs SNFs while §1919(b)(6)(A) of the Act governs NFs. For further 

information, refer to Medlearn Matters article number SE0418 at www.cms.hhs.gov/medlearn/matters 

The initial visit in a SNF and NF must be performed by the physician except as otherwise permitted 

(42CFR483.40(c)(4)). The initial visit is defined in as the initial comprehensive assessment visit during 

which the physician [Emphasis Added] completes a thorough assessment, develops a plan of care and 

writes or verifies admitting orders for the nursing facility resident. For Survey and Certification 

requirements, a visit must occur no later than 30 days after admission. 

Further, per the Long Term Care regulations at 42CFR483.40(c)(4) and (e)(2), the physician may not 

delegate [Emphasis Added] a task that the physician must personally perform. Therefore, the physician 

may not delegate the initial visit in a SNF. This also applies to the NF with one exception. 

The only exception, as to who performs the initial visit, relates to the NF setting [Emphasis Added]. In 

the NF setting, a qualified NPP [Emphasis Added] (i.e., a nurse practitioner (NP), physician assistant 

(PA), or a clinical nurse specialist (CNS), who is not employed by the facility, may perform the initial 

visit [Emphasis Added] when the State law permits. The evaluation and management (E/M) visit shall be 

within the State scope of practice and licensure requirements where the E/M visit is performed and the 

requirements for physician collaboration and physician supervision shall be met. 

Under Medicare Part B payment policy, other medically necessary E/M visits may be performed and 

reported prior to and after the initial visit, if the medical needs of the patient require an E/M visit. A 

qualified NPP may perform medically necessary E/M visits prior to and after the initial visit if all the 

requirements for collaboration, general physician supervision, licensure and billing are met. 

5-39 




The CPT Nursing Facility Services codes shall be used with place of service (POS) 31 (SNF) if the 

patient is in a Part A SNF stay. They shall be used with POS 32 (nursing facility) if the patient does not 

have Part A SNF benefits or if the patient is in a NF or in a non-covered SNF stay (e.g., there was no 

preceding 3-day hospital stay). The CPT Nursing Facility code definition also includes POS 54 

(Intermediate Care Facility/Mentally Retarded) and POS 56 (Psychiatric Residential Treatment Center). 

Initial Nursing Facility Care, per day, (99304–99306) are used to report the initial visit. Only a physician 

may report these codes for an initial visit performed in a SNF or NF (with the exception of the qualified 

NPP in the NF setting who is not employed by the facility and when State law permits, as explained 

above). 

A readmission to a SNF or NF shall have the same payment policy requirements as an initial admission in 

both the SNF and NF settings. 

A physician who is employed by the SNF/NF may perform the E/M visits and bill independently to 

Medicare Part B for payment. An NPP who is employed by the SNF or NF may perform and bill 

Medicare Part B directly for those services where it is permitted as discussed above. The employer of the 

PA shall always report the visits performed by the PA. A physician, NP or CNS has the option to bill 

Medicare directly or to reassign payment for his/her professional service to the facility. 

As with all E/M visits for Medicare Part B payment policy, the E/M documentation guidelines apply. 

B. Visits to Comply With Federal Regulations (42 CFR 483.40 (c) (1)) in the SNF and NF 

Payment is made under the physician fee schedule by Medicare Part B for federally mandated visits. 

Following the initial visit by the physician, payment shall be made for federally mandated visits that 

monitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least 

once every 60 days thereafter. 

Subsequent Nursing Facility Care, per day, codes 99307–99310 are used to report federally mandated 

physician E/M visits and medically necessary E/M visits. 

Carriers shall not pay for more than one E/M visit performed by the physician or qualified NPP for the 

same patient on the same date of service. The Nursing Facility Services codes represent a “per day” 

service. 

The federally mandated E/M visit may serve also as a medically necessary E/M visit if the situation arises 

(i.e., the patient has health problems that need attention on the day the scheduled mandated physician E/M 

visit occurs). The physician/qualified NPP shall bill only one E/M visit. 

Other Nursing Facility Service (99318), is used to report an annual nursing facility assessment visit on the 

required schedule of visits on an annual basis. For Medicare Part B payment policy, an annual nursing 

facility assessment visit code may substitute as meeting one of the federally mandated physician visits if 

the code requirements for CPT code 99318 are fully met and in lieu of reporting a Subsequent Nursing 

Facility Care, per day, service (codes 99307–99310). It shall not be performed in addition to the required 

number of federally mandated physician visits. Qualified NPPs, whether employed or not by the SNF, 

may perform alternating federally mandated physician visits, at the option of the physician, after the 

initial visit by the physician in a SNF. 

Qualified NPPs in the NF setting, who are not employed by the NF, may perform federally mandated 

physician visits, at the option of the State, after the initial visit by the physician. 

5-40 




Medicare Part B payment policy does not pay for additional E/M visits that may be required by State law 

for a facility admission or for other additional visits to satisfy facility or other administrative purposes. 

E/M visits, prior to and after the initial physician visit, that are reasonable and medically necessary to 

meet the medical needs of the individual patient (unrelated to any State requirement or administrative 

purpose) are payable under Medicare Part B. 

C. Visits by Qualified Nonphysician Practitioners 

All E/M visits shall be within the State scope of practice and licensure requirements where the visit is 

performed and all the requirements for physician collaboration and physician supervision shall be met 

when performed and reported by qualified NPPs. General physician supervision and employer billing 

requirements shall be met for PA services in addition to the PA meeting the State scope of practice and 

licensure requirements where the E/M visit is performed. 

Medically Necessary Visits 

Qualified NPPs may perform medically necessary E/M visits prior to and after the physician’s initial visit 

in both the SNF and NF. Medically necessary E/M visits for the diagnosis or treatment of an illness or 

injury or to improve the functioning of a malformed body member are payable under the physician fee 

schedule under Medicare Part B. CPT codes, Subsequent Nursing Facility Care, per day (99307-99310), 

shall be reported for these E/M visits even if the visits are provided prior to the initial visit by the 

physician. 

SNF Setting--Place of Service Code 31 

Following the initial visit by the physician, the physician may delegate alternate federally mandated 

physician visits to a qualified NPP who meets collaboration and physician supervision requirements and 

is licensed as such by the State and performing within the scope of practice in that State. 

NF Setting--Place of Service Code 32 

Per the regulations at 42CFR483.40(f), a qualified NPP, who meets the collaboration and physician 

supervision requirements, the State scope of practice and licensure requirements, and who is not 

employed by the NF, may at the option of the State, perform the initial visit in a NF, and may perform 

any other federally mandated physician visit in a NF in addition to performing other medically necessary 

E/M visits. 

Questions pertaining to writing orders or certification and recertification issues in the SNF and NF 

settings shall be addressed to the appropriate State Survey and Certification Agency departments for 

clarification. 

D. Medically Complex Care 

Payment is made for E/M visits to patients in a SNF who are receiving services for medically complex 

care upon discharge from an acute care facility when the visits are reasonable and medically necessary 

and documented in the medical record. Physicians and qualified NPPs shall report E/M visits using the 

Subsequent Nursing Facility Care, per day (codes 99307-99310) for these E/M visits even if the visits are 

provided prior to the initial visit by the physician. 

E. Incident to Services 

Where a physician establishes an office in a SNF/NF, the “incident to” services and requirements are 

confined to this discrete 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 SNF/NF setting and shall not be reported using the CPT codes for office or 

other outpatient visits or use place of service code 11. 

5-41 




F. Not Pertinent to this Handout 

G. Not Pertinent to this Handout 

H. Split/Shared E/M Visit 

A split/shared E/M visit cannot [Emphasis Added] be reported in the SNF/NF setting. A split/shared E/M 

visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient 

where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit 

face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit 

involves all or some portion of the history, exam, or medical decision making key components of an E/M 

service. The physician and the qualified NPP must be in the same group practice or be employed by the 

same employer. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital 

inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and 

non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M 

policy does not apply to consultation services, critical care services, or procedures. 

I. SNF/NF Discharge Day Management Service 

Medicare Part B payment policy requires a face-to-face visit with the patient provided by the physician or 

the qualified NPP to meet the SNF/NF discharge day management service as defined by the CPT code. 

The E/M discharge day management visit shall be reported for the date of the actual visit by the physician 

or qualified NPP even if the patient is discharged from the facility on a different calendar date. The CPT 

codes 99315 – 99316 shall be reported for this visit. The Discharge Day Management Service may be 

reported using CPT code 99315 or 99316, depending on the code requirement, for a patient who has 

expired, but only if the physician or qualified NPP personally performed the death pronouncement. 

99315 30 minutes or less 

99316 greater than 30 minutes 

DOMICILIARY CARE – CPT CODES 99324-99337 

There are five levels of care for the evaluation and management of new patients. Codes 99324-99328 

include the type of history, exam, and medical decision making as well as the typical time spent 

performing the service. Thus, these codes can be selected by time with more than 50 percent of the time is 

spent in counseling or coordination of care. 

Codes 99334-99337 provide four levels of care for the evaluation and management of established 

patients. These codes can be based on the content of the service provided (history, exam, and medical 

decision making) or by time when more than 50 percent of the time is spent in counseling or coordination 

of care. 

Place of service “13” - Assisted Living Facility – Definition: Congregate residential facility with selfcontained 

living units providing assessment of each resident's needs and on-site support 24 hours a day, 7 

days a week, with the capacity to deliver or arrange for services including some health care and other 

services. 

5-42 




HOME SERVICES – CPT CODES 99341-99350 

Medicare Claims Processing Manual Chapter 12 §30.6.14.1 (Codes 99341-99350) (Rev. 1, 10-01-03) B3- 

15515, B3-15066 

A. Requirement for Physician Presence 

Home services codes 99341-99350 are paid when they are billed to report evaluation and management 

services provided in a private residence. A home visit cannot be billed by a physician unless the physician 

was actually present in the beneficiary’s home. 

B. Homebound Status 

Under the home health benefit, the beneficiary must be confined to the home for services to be covered. 

For home services provided by a physician using these codes, the beneficiary does not need to be 

confined to the home. The medical record must document the medical necessity of the home visit made 

in lieu of an office or outpatient visit. [Emphasis Added] 

SCREENING PAP SMEARS AND SCREENING PELVIC EXAMINATION 

(INCLUDING CLINICAL BREAST EXAM) 

Medicare Benefit Policy Manual Chapter 15 §280.4 (Rev. 1, 10-01-03) A3-3628.1, B3-4603.1 

Effective, July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L. 106-554) modifies §1861(nn) 

to provide Medicare coverage for biennial screening Pap smears or more frequent coverage for women: 

1. At high-risk for cervical or vaginal cancer 

2. Of childbearing age who have had a Pap smear during any of the preceding three years indicating 

the presence of cervical or vaginal cancer or other abnormality 

Cervical Cancer High-Risk Factors 

1. Early onset of sexual activity (under 16 years of age) 

2. Multiple sexual partners (five (5) or more in a lifetime) 

3. History of a sexually transmitted disease (including HIV infection) 

4. Fewer than three negative or any Pap smears within the previous seven years 

Vaginal Cancer High Risk Factors 

1. DES (diethylstilbestrol) - exposed daughters of women who took DES during pregnancy 

The term “woman of childbearing age” means a woman who is premenopausal, and has been determined 

by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other 

findings. Payment is not made for a screening Pap smear for women at high-risk or who qualify for 

coverage under the childbearing provision more frequently than once every 11 months after the month 

that the last screening Pap smear covered by Medicare was performed. 

For Claims with Dates of Service on or After July 1, 2001 

When the beneficiary does not qualify for a more frequently performed screening Pap smear as noted in 

items 1 and 2 above, contractors pay for the screening Pap smear only after at least 23 months have 

passed following the month during which the beneficiary received her last covered screening Pap smear. 

All other coverage and payment requirements remain the same. 

5-43 




Screening Pelvic Examinations 

Medicare Claims Processing Manual Chapter 18 §40 (Rev. 1, 10-01-03) B3-4603.2, A3-3, 3628.1B 

§4102 of the Balanced Budget Act of 1997 provides for coverage of screening pelvic examinations 

(including a clinical breast examination) for all female beneficiaries, subject to certain frequency and 

other limitations. 

A screening pelvic examination (including a clinical breast examination) should include at least seven (7) 

of the following eleven (11) elements: 

• Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple 

discharge 

• Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses 

Pelvic examination (with or without specimen collection for smears and cultures) including: 

• External genitalia (for example, general appearance, hair distribution, or lesions) 

• Urethral meatus (for example, size, location, lesions, or prolapse) 

• Urethra (for example, masses, tenderness, or scarring) 

• Bladder (for example, fullness, masses, or tenderness) 

• Vagina (for example, general appearance, estrogen effect, discharge lesions, pelvic support, 

cystocele, or rectocele) 

• Cervix (for example, general appearance, lesions, or discharge) 

• Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or 

support) 

• Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity) 

• Anus and perineum 

Coding for Screening Pelvic Examinations 

Medicare Claims Processing Manual Chapter 18 §40.2 (Rev. 1, 10-01-03) B3-4603.2.B and C, A3- 

3628.1.B.1 

A HCPCS code has been established for the pelvic and clinical breast examinations. Use code G0101 

(cervical or vaginal cancer screening, pelvic and clinical breast examination). 

Coding for Obtaining the Pap smear 

Medicare Claims Processing Manual Chapter 18 §30.5.D (Rev. 795, Issued: 12-30-05; Effective: 10-01- 

04; Implementation: 04-03-06) 

Use HCPCS code Q0091 to report the obtaining a screening pap smear during an encounter. This code is 

subject to the same frequencies and diagnoses as pelvic and clinical breast exam. 

Payment for Q0091 is paid under the Medicare physician fee schedule. Deductible is not applicable, 

however the coinsurance applies. 

Effective for services on and after July 1, 2005, on those occasions when physicians must perform a 

screening Pap smear (Q0091) that they know will not be covered by Medicare because the low risk 

patient has already received a covered Pap smear (Q0091) in the past 2 years, the physician can bill 

Q0091 and the claim will be denied appropriately. 

The physician shall obtain an advance beneficiary notice (ABN) in these situations as the denial will be 

considered a not reasonable and necessary denial. The physician indicates on the claim that an ABN has 

been obtained by using the GA modifier. 

Effective for services on or after April 1, 1999, a covered evaluation and management (E/M) visit and 

code Q0091 may be reported by the same physician for the same date of service if the E/M visit is for a 

separately identifiable service. In this case, the modifier “-25” must be reported with the E/M service and 

5-44 




the medical records must clearly document the E/M reported. Both procedure codes should be shown as 

separate line items on the claim. These services can also be performed separately on separate office visits. 

Repeat Obtaining Screening Pap Smear Due To Inadequate Specimen 

Related Change Request (CR) #: 3659 Medlearn Matters Number: MM3659 Related CR Transmittal #: 

440 Implementation Date: July 5, 2005 

When a Pap smear specimen is not sufficient for the laboratory to interpret the results and another 

specimen is needed report Q0091 and append the -76 modifier to indicate it is a repeat specimen. The 

Carrier will pay for the collection of the specimen. Physicians should not report the screening pelvic 

examination again as the entire service is not medically necessary. It is also inappropriate to report an 

E/M code unless the patient has another problem needing a medically necessary evaluation on the same 

date of service. 

CMS Incident To Clarification 

CMS Region V clarified that screening pelvic examination with clinical breast exam (G0101) and 

obtaining screening Pap smear (Q0091) cannot be billed “incident to” the physician’s services. The 

physician or nonphysician practitioner who PERFORMS the service(s) must report these screening 

services. This clarification applies to all screening services. 

Covered Diagnoses For Reporting Screening Pelvic Examination Or The Obtaining Of A Screening 

Pap Smear 

Medicare Claims Processing Manual Chapter 18 §30.6 (Rev. 1, 10-01-03) AB-03-054 (CR 2637) (Rev. 

440, Issued: 01-21-05, Effective: 07-01-05, Implementation: 07-05-05) 

Applicable Diagnoses for Billing a Carrier 

There are a number of appropriate diagnosis codes that can be used in billing for screening Pap smear 

services that the provider can list on the claim to give a true picture of the patient’s condition. To be 

covered one of the following diagnoses must be listed in Item 21 of Form CMS-1500 or the electronic 

equivalent. 

Below are the current diagnoses that should be used when billing for screening Pap smear services. 

Effective, July 1, 2005, V72.31 is being added to the CWF edit as an additional low risk diagnosis. The 

following chart lists the diagnosis codes that CWF must recognize for low risk or high-risk patients for 

screening Pap smear services. 

Low Risk Definitions 

Diagnosis Codes 

V76.2 Special screening for malignant neoplasms, cervix 

V76.47 Special screening for malignant neoplasm, vagina 

V76.49 Special screening for malignant neoplasm, other sites 

NOTE: providers use this diagnosis for women without a cervix. 

V72.31 Routine gynecological examination 

NOTE: This diagnosis should only be used when the provider 

performs a full gynecological examination. 

High Risk Diagnosis Code 

V15.89 Other 

If one of these diagnoses is not present or if the frequency requirements are not met, the CWF will reject 

the claim as “not medically necessary.” 

5-45 




RISK ASSESSMENT FORM 

A screening pelvic examination (including a clinical breast examination) and/or screening pap smear is a 

covered Medicare service once every two years, unless a patient is considered high-risk for cervical or 

vaginal cancer. Listed below are the criteria considered to be high-risk. If you meet any of the following, 

and wish to share this information with us, the screening pelvic and/or screening pap may be paid 

annually. 

_____ Childbearing age and have had an examination indicating the presence of cervical or 

vaginal cancer or other abnormality during any of the preceding three years 

_____ Early onset of sexual activity (under 16 years of age) 

_____ Multiple sexual partners (five or more in a lifetime) 

_____ History of sexually transmitted disease (including the human immunodeficiency virus 

[HIV]) 

_____ Any of the last three pap smears were positive 

_____ No pap smear within the past seven years 

_____ Prenatal exposure to diethylstilbestrol 

OR 

_____ None of the above (payment may be made by Medicare once every two years) 

__________________________________________ 

Signature 

________________________ 

Date 


Only Are Copyright 2006 American Medical Association. IAFP Annual Meeting 2007 


46

pqri measure coding and reporting principles - Indiana Academy of ...

Create successful ePaper yourself

Delete template?

Save as template?