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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 *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.
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 *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.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41: Medicare Part B payment policy does
Page 45 and 46: the medical records must clearly do

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