Medicare Compliance & Reimbursement

Learn how these CMS changes will affect your E/M coding and reimbursement. Coding for prolonged services can be daunting. But thanks to Medicare changes coming down the pike, CMS' expectations will be a little clearer. What's in store, and how can these changes help you ratchet up your practice's reimbursement? 1. Document Start And Stop Time, CMS Says Keep an eye on the clock: According to Medicare Transmittal 1490, effective July 1, "When reporting prolonged services, the provider shall document both the visit start and end time in the medical record along with the date of service," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, with MJH Consulting. You can find the transmittal online at http://www.cms.hhs.gov/transmittals/downloads/R1490CP.pdf. Why it matters: "The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions," the transmittal states. But don't forget: Prolonged service codes 99354-99357 require "face-to-face" patient care. That doesn't mean, however, that the time must be continuous. The encounter doesn't have to be one long face-to-face session, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, PA. Example: A physician visits a patient in the morning and, upon reviewing all of the patient's clinical information, decides that the patient needs another diagnostic study. The patient leaves to get the test and comes back that afternoon to discuss treatment options with the physician, who reviews the test results. You may be able to report a prolonged service code in this case even though the time the physician spent with the patient wasn't continuous, Falbo says. Just be sure the start and stop times are included in the documentation. 2. Avoid Rounding For Time-Based E/M Choices Warning: When you choose an E/M code level based on time spent on counseling and/or coordination of care (C/C), remember that Medicare has its own prolonged service rules. Rule: Transmittal 1490 clarifies that when you report prolonged services as an add-on to E/M codes based on C/C (time-based), "the time approximation for the E/M service must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be 'rounded' to the next higher level," Hammer says. What it means: If you base the E/M service level on time spent in C/C, the total face-to-face time has to meet or exceed the "typical time threshold" for that service level, Hammer says. You can't "round up" after meeting a halfway point as you can with many other time-based codes (such as physical therapy services), Hammer says. She cites [...]