Skilled Nursing Facility 3-Day Rule Billing

To qualify for Skilled Nursing Facility (SNF) extended care services coverage, Medicare patients must meet the 3-day rule before SNF admission. 

The 3-day rule requires,

• Three-day-consecutive inpatient hospital stay. 
• Three-day-consecutive stay counts inpatient setting.
• Starting with the calendar day of hospital admission.
• Doesn’t include the day of discharge or any pre-admission time spent in the ER or outpatient observation.

SNF extended care services are an extension of care a patient needs after a hospital discharge or within 30 days of their hospital stay (unless admitting them within 30 days is medically inappropriate).

Example

A 68-year-old male patient went to the hospital ER after falling on May 17th from his home and a physician admitted him to the hospital on the same day. On subsequently May 20, the hospital discharged him to SNF extended care services. 

For this case, the patient did qualify the 3-day rule. Hospitals can count the admission day (May 17th to May19th), but not the discharge day (May 20). 

Tips

Medicare considered inpatients meet the 3-day rule by staying 3 consecutive days in 1 or more hospital(s) as well.

See Inpatient Guidelines

New ICD codes for COVID-19

In March 2020 the Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization.

The Centers for Disease Control (CDC), under the National Emergencies Act Section 201 and 301, is announcing further additions to the ICD-10-CM Classification related to COVID-19, which will become effective January 1, 2021.

As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and\ Prevention’s National Center for Health Statistics (CDC/NCHS) is implementing additional codes into ICD-10-CM for reporting to include,

• Encounter for screening for COVID-19  - Z11.52
• Contact with and (suspected) exposure to COVID-19 - Z20.822
• Personal history of COVID-19 - Z86.16
• Multisystem inflammatory syndrome (MIS) - M35.81
• Other specified systemic involvement of connective tissue - M35.89
• Pneumonia due to coronavirus disease 2019 - J12.82
• COVID-19 Positive - U07.1

These new codes will be effective January 1, 2021, to identify conditions resulting from COVID-19.

Check Related information

Cognitive Assessment Written Care Plan

A patient presents with cognitive impairment and or identified during the encounter then Medicare covers a separate visit for a cognitive assessment.

So, the provider can more thoroughly evaluate the patients for cognitive function and help with care planning.

Any clinician eligible to report evaluation and management services can offer this service, including physicians (MD and DO), nurse practitioners, clinical nurse specialists, and physician assistants.

The Cognitive Assessment & Care Plan Services (CPT code 99483) typically start with a 50-minute face-to-face visit that includes a detailed history and patient exam.

The physician can collect the information from the physical examination to create a written care plan.

The resulting written care plan includes initial plans to address as following,

• Neuropsychiatric symptoms
• Neurocognitive symptoms
• Functional limitations

The Patient and or caregiver referrals to community resources, as needed, with initial education and support.

Effective from January 1, 2021, Medicare increased payment for these services to $282 when provided in an office setting, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently covers these services via telehealth.

Click here for Guidelines

Frequently Used Place of Service - POS

The below-mentioned place of service codes is used more frequently. Check the detail updates following,

Frequently Used Place of Service

• 2 Telehealth
• 11 Office
• 12 Home
• 13 Assisted Living Facility
• 15 Mobile Unit
• 19 Off Campus-Outpatient Hospital
• 20 Urgent Care Facility
• 21 Inpatient Hospital
• 22 On Campus-Outpatient Hospital
• 23 Emergency Room – Hospital
• 24 Ambulatory Surgical Center
• 31 Skilled Nursing Facility
• 32 Nursing Facility
• 33 Custodial Care Facility
• 34 Hospice
• 49 Independent Clinic
• 51 Inpatient Psychiatric Facility
• 52 Psychiatric Facility-Partial Hospitalization

Insight about Place of Services

 

POS - 2 The location where health services and health-related services are provided or received, through a telecommunication system.

POS - 11 Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

POS - 12 Location, other than a hospital or other facility, where the patient receives care in a private residence.

POS - 13 Congregate residential facility with self-contained 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.

POS - 15 A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.

POS - 19 A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS - 20 Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

POS - 21 A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

POS - 22 A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Description change

POS - 23 A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

POS - 24 A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.

POS - 31 A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

POS - 32 A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than individuals with intellectual disabilities.

POS - 33 A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

POS - 34 A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.

POS - 49 A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.

POS - 51 A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

POS - 52 A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full-time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.

To learn about modifier information click here

Update for COVID -19 CPT 87637

The Modifier QW is defined as a Clinical Laboratory Improvement Amendment (CLIA) waived test and it is used to identify waived tests and would be submitted in the first modifier field.

The modifier QW is accepted by CMS for CPT 87637 and effective from date October 06,2020 and the implementation date July 06, 2021.

Also, the modifier QW allowed for HCPCS code 0240U & 0241U

87637 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique

0240U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected

0241U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected

Return related information 

Home Monitoring PT INR Guidelines

The beneficiary requires chronic oral anticoagulation with warfarin for a mechanical heart valve, chronic atrial fibrillation, or venous thromboembolism inclusive of deep venous thrombosis and pulmonary embolism on warfarin.

The patient has been anticoagulated for at least three months prior to use of the home INR device and he/she undergone a face-to-face educational program on anticoagulation management and demonstrated the correct use of the device prior to its use in the home.

The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following initiation of home monitoring and home-testing with the device occurs no more frequently than once a week

Managing Anti-Coagulation

There are at least three strategies for managing warfarin anticoagulation,

• Physician office-based testing and management
• Anticoagulation clinics
• Home PT/INR monitoring with patient reporting or physician-directed self-management.

Most patients being anticoagulated are managed through physician offices, the "usual care" approach.

Individual physicians manage their patients and PT/INR test frequency is generally once every 4-6 weeks. 

The physician's service is billed with procedure code G0250, no more frequently than once every 4 weeks or every 28 days (7 days/week x 4 = 28 days). There must be 28 days between each submission of G0250.

Clinical Example

• Patient tests 4 times, on Fridays, in April of 2021
• The patient tested on April 2, 9, 16, and 23
• Physician bills G0250 on April 23,2021
• A physician can only bill G0250 once every 4 weeks (28 days)

Covered ICD Codes

• I26.93       Single subsegmental pulmonary embolism without acute cor pulmonale
• I26.94       Multiple subsegmental pulmonary embolism without acute cor pulmonale
• I48.0         Paroxysmal atrial fibrillation
• I48.11       Longstanding persistent atrial fibrillation
• I48.19       Other persistent atrial fibrillation
• I48.20       Chronic atrial fibrillation, unspecified
• I48.21       Permanent atrial fibrillation
• I48.3         Typical atrial flutter
• I48.4         Atypical atrial flutter
• I48.91       Unspecified atrial fibrillation
• I48.92       Unspecified atrial flutter
• I49.02       Ventricular flutter
• O88.211    Thromboembolism in pregnancy, first trimester
• O88.212    Thromboembolism in pregnancy, second trimester
• O88.213    Thromboembolism in pregnancy, third trimester
• O88.219    Thromboembolism in pregnancy, unspecified trimester
• O88.22      Thromboembolism in childbirth
• O88.23      Thromboembolism in the puerperium       
• T82.01XA Breakdown (mechanical) of heart valve prosthesis, initial encounter
• T82.02XA Displacement of heart valve prosthesis, initial encounter
• T82.03XA Leakage of heart valve prosthesis, initial encounter
• T82.09XA Other mechanical complication of heart valve prosthesis, initial encounter
• T82.110A  Breakdown (mechanical) of cardiac electrode, initial encounter
• T82.111A  Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter
• T82.118A  Breakdown (mechanical) of other cardiac electronic device, initial encounter
• T82.119A  Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter
• T82.120A  Displacement of cardiac electrode, initial encounter
• T82.121A  Displacement of cardiac pulse generator (battery), initial encounter
• T82.128A  Displacement of other cardiac electronic device, initial encounter
• T82.129A  Displacement of unspecified cardiac electronic device, initial encounter
• T82.190A  Other mechanical complication of cardiac electrode, initial encounter
• T82.191A  Other mechanical complication of cardiac pulse generator (battery), initial encounter
• T82.198A  Other mechanical complication of other cardiac electronic device, initial encounter
• T82.199A  Other mechanical complication of unspecified cardiac device, initial encounter
• Z95.2         Presence of prosthetic heart valve
• Z95.3         Presence of xenogenic heart valve
• Z95.4         Presence of other heart-valve replacement
• Z95.5         Presence of coronary angioplasty implant and graft
• Z95.810     Presence of automatic (implantable) cardiac defibrillator
• Z95.811     Presence of heart assist device
• Z95.818     Presence of other cardiac implants and grafts
• Z95.9         Presence of cardiac and vascular implant and graft, unspecified

Tips

• Self-testing with the device is limited to a frequency of once per week.

• Testing more frequently than once per week is generally considered not medically necessary.

• Billing units of service include 4 tests

• The date of service should be considered as - End date of the final test.

PT/INR - Home Monitoring Codes are, G0248, G0249 & G0250,

• G0248 - The provider demonstrates the use and care of an INR monitor,

• G0249 - For home INR monitoring supplies,

• G0250 - Physician review, interpretation, and patient management of home INR testing for patient 

Note: 

The billing of CPT code G0250 is subject to a 28-day rule. This means that the physician cannot submit a claim for G0250 earlier than 28 days from the date of the last bill for the same service for the same patient. 

There must be 28 full days between each submission date. If G0250 is submitted within 28 days, the claim will be denied.

Check RPM (Remote Patient Monitoring) Guidelines 

RPM - Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) technology comes in various devices that monitor glucose levels, BP, weight management, sleep patterns, heart rate, vital signs, and many other types of patient data.

RPM allows patients to be involved in their own care by giving them access to their health data in real-time.

For providing RPM services to the patients and staff time spent monitoring the respective beneficiary. These actions are billable through four CPT codes,

• 99453 - Initial set up and patient education
• 99454 - Supply of devices and collection, transmission, and summary of services
• 99457 - First 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP
• 99458 - For an additional 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP

Initial Set-Up & Patient Education - CPT 99453

• It is reported for each episode of care.

• An episode of care is defined as beginning when the remote monitoring physiologic service is initiated and ends with the attainment of targeted treatment goals.

• CPT 99453 should not be reported, “If monitoring is less than 16 days.” If, for example, a patient receives and is educated on the device, but no data is transmitted by the device, one could not bill for CPT 99453.

Supply of Device - CPT 99454

• It is used to report the supply of the device for daily recording or programmed alert transmissions over a 30-day period provided monitoring occurs at least 16 days during the 30-day period.

• CPT 99453 & 99454 should not be reported “when these services are included in other codes for the duration of time of the physiologic monitoring service" (e.g., 95250 for continuous glucose monitoring requires a minimum of 72 hours of monitoring).

Monitoring & treatment Management services - CPT 99457 & 99458

• It requires live, interactive communication with the patient/caregiver and 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month.

• Can be billed once in 30 days.

• Time spent by clinical staff may be counted toward the 20 minutes only if services are furnished under direct supervision.

CPT Guidelines

• Time of fewer than 20 minutes during a calendar month cannot be billed with CPT 99457.

• Time over 20 minutes in one month cannot be carried forward to the next month.

• 99457 may be reported during the same service period as chronic care management services (99487, 99489, 99490), transitional care management services (99495, 99496), and behavioral health integration services (99484, 99492, 99493, 99494). 

• However, time spent performing these services should remain separate and no time should be counted toward the required time for both services in a single month.

• Report CPT 99457 one time regardless of the number of physiologic monitoring modalities performed in a given calendar month.

• “live interactive communication,” means a face-to-face visit, an interactive video conference (e.g., Face Time), or a conversation by telephone or text message would be sufficient. A record of such communication should be included within the documentation for the service.

RPM Billing Requirements

• The place of service would be the location at which the billing physician maintains his or her practice (i.e., physician office vs. hospital outpatient department).

• A beneficiary may have two monitoring devices with one supplied by the physician monitoring one chronic condition and one by another physician monitoring another condition, and both physicians would be eligible for payment.

See Complex Chronic Care Service

Evaluation and Management - Inpatient Setting

Initial hospital care is reported for a patient who is being admitted to the hospital as an inpatient. The level of service is decided based on the three major key components of history, examination, and medical decision-making.

There are divided into three types.

1. Inpatient Admit or Initial Care - 99221,99222 & 99223
2. Subsequent Hospital or Follow Up - 99231, 99232 & 99233
3. Discharges - 99238 & 99239

Guidelines

Do not report another E/M service along with the inpatient admission code even though if the patient is seen by the same physician for a different reason on the same day.

E.g., 

The physician sees the patient in the ED and after a thorough examination, decides to admit the patient to the hospital.

Report only the appropriate level of inpatient admission code and the ED service is considered the part of admission services when the same service is rendered by the same provider.

If the admission is on a subsequent date from an ED service, both the services can be reported respectively. 

Same day Admission and discharge refer below CPT codes,

• 99234 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A detailed or comprehensive history, A detailed or comprehensive examination; and straightforward or of low complexity of MDM
• 99235 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and moderate complexity of MDM
• 99236 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and High complexity MDM

Additional Information

The selection of a level of E/M service depends mainly on the three major components: 

• History, Examination, and Medical Decision Making (MDM). 
• The other components that might affect the decision-making are the nature of presenting the problem, time, coordination of care, and counseling.

History consists of four components: Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), and Past Family and Social History (PFSH).

Physical Examination: Physical examination is the examination of the organ systems or different body areas relevant to the current disease/disorder.

MDM -Medical Decision Making: After gathering information, the clinician must decide what to do. That thinking process, which takes into account risk factors, is MDM.

It has three components like,

• A number of diagnosis and treatment options.
• The amount and/or complexity of data reviewed.
• The risk of complications, morbidity, and/or mortality involved.

Tips

The admitting physicians can be reported with modifier "AI" for CPT 99221 to 99223 when the patient has "Medicare and Medicare HMO's" insurances since Medicare & HMO's plan would not be covered Consultation services hence Consulting physician can be reported the admit CPT's.

When more than one admits service is billed within the same inpatient setting, the modifier "AI" is denoted as " Principal physician" it will help the insurance to identify the admitting physician's name vs Consulting Physician's names.


Return to related information

Vaccine CPT codes Billing Guidelines

There are four different types of administration of vaccine CPT codes found.

1. Pediatrics patients up to 18 years of age - CPT 90460 & 90461.
2. Adult age patients - CPT 90471 & 90472.
3. For Intranasal or oral route - CPT 90473 & 90474
4. For COVID-19 vaccines - CPT 001A, 0002A, 0011A, 0012A, 0021A, 0022A, 0031A, 0041A, 0042A

If the provider and or other qualified healthcare professional administers more than one vaccine, use the appropriate add-on codes.

90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

+90461 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

90471 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

+90472 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

90473 - Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

+90474 - Immunization administration by the intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

Examples

Diphtheria and Tetanus Toxoids Adsorbed vaccine 2 components administered to a pediatric patient and provided and counseling to the patient and parents by a physician.

• The appropriate administration is billed with one each CPT 90460 and 90461 instead of a single code.

Fluzone Quadrivalent vaccine, a single-component vaccine, is administered to a pediatric patient and counseling is provided by the physician.

• The appropriate administration code 90460 with only one unit.

Pentacel vaccine, a 5-component vaccine, is administered to a pediatric patient, and counseling is provided by the other qualified healthcare practitioner.

• The appropriate administration CPT code 90460 with one unit and 4 units for CPT 90461

Flublok and Quadrivalent and Adacel vaccines are administered to an adult patient.

• 90471and 90472 can be billed one unit for each code.

Return to COVID-19 Updates

Annual Preventive and Wellness Visit Service

Preventive Service Codes

The annual preventive exam is a periodic, comprehensive preventive medicine evaluation (or reevaluation) and management of the patient.

The CPT Code selection is based on whether the patient is receiving an initial visit -"New Patient" or a periodic - "Established Patient" preventive service, as well as the patient’s age.

• Initial Visits - 99381, 99382, 99383, 99384, 99385, 99386, 99387
• Subsequent Visits - 99391, 99392, 99393, 99394, 99395, 99396, 99397

The Medicare insurance would be covered by "G" codes instead of the above codes. The details below,

• Welcome to Medicare - G0402 (Within the one year from the patient enrolled in Medicare)
• Initial Annual Wellness Visit - G0438 (After the 1st year of enrollment)
• Subsequent Annual Wellness Visit - G0439

Initial Visits

Initial comprehensive preventive medicine evaluation and management of an individual including an" age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures", New patient,

• 99381 - Infant (age younger than 1 year)
• 99382 - Early childhood (age 1 through 4 years)
• 99383 - Late childhood (age 5 through 11 years)
• 99384 - Adolescent (age 12 through 17 years)
• 99385 - 18-39 years
• 99386 - 40-64 years
• 99387 - 65 years and older

Subsequent Visits

Periodic comprehensive preventive medicine reevaluation and management of an individual including an "age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures," established patient,

• 99391 - Infant (age younger than 1 year)
• 99392 - Early childhood (age 1 through 4 years)
• 99393 - Late childhood (age 5 through 11 years)
• 99394 - Adolescent (age 12 through 17 years)
• 99395 - 18-39 years
• 99396 - 40-64 years
• 99397 - 65 years and older

Included Services

Checking the status of "chronic conditions" and "refilling ongoing prescriptions" is expected during an annual preventive exam and does not warrant the billing of a separate problem-oriented E/M service.

If a chronic condition is not being well controlled, however, and decisions are being made as to how to treat the patient to improve control (changing the dosage of medications, changing to a new medication, etc.), this may substantiate a separate problem-oriented E/M service.

Documentation

• Medical and family history
• List of current medical providers
• Height, weight, BMI, BP, and other appropriate routine measurements
• Detection of cognitive impairment
• Review risk factors – Review of functional ability
• Establish a written screening schedule for the next 5-10 years
• Establish a list of risk factors
• Provide advice and referrals to health education and preventative counseling services

Tips - CPT G0402 & G0438 covered once in a lifetime for the patient.

See E/M 2021E&M guidelines

Level of History - Evaluation and Management

Definition and Details of  History

Level of  History

There are four levels of History found in E/M,

• Problem Focused History
• Expanded Problem Focused History
• Detailed History
• Comprehensive History  

The problem focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), 

The Expanded Problem Focused History requires documentation of the chief complaint (CC) and a brief history of present illness (HPI) and Problem Pertinent review of system

The Detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS), and pertinent past, family, and/or social history (PFSH).

The Comprehensive history requires the documentation of a CC, an extended HPI, plus an Complete review of systems (ROS), and Complete past, family, and/or social history (PFSH).

Chief Complaint (CC) 

A Chief Complaint or reason visit/ reason for appointment is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. 

The CC is usually stated in the patient’s own words. For example, patient complains of chest pain and radiating to shoulder, and  denied shortness of breath. The medical record should clearly reflect the CC.

History of Present Illness (HPI) 

The HPI is a chronological description of the development of the patient’s present illness from the first sign and/ or symptom or from the previous encounter to the present

The HPI elements are,

• Location (example: left leg)
• Quality (example: aching, burning, radiating pain)
• Severity (example: 10 on a scale of 1 to 10)
• Duration (example: started 3 days ago)
• Timing (example: constant or comes and goes)
• Context (example: lifted large object at work)
• Modifying factors (example: better when heat is applied)
• Associated signs and symptoms (example: numbness in toes) 

There are two types of HPI,

A Brief HPI includes documentation of one to three HPI elements. 

An Extended HPI, 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities. In 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions

Review of Systems (ROS)

ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced. 

These systems are recognized for ROS purposes,

• Constitutional Symptoms (for example, fever, weight loss)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

The three types of ROS are problem pertinent, extended, and complete.

A Problem Pertinent ROS inquires about the system directly related to the problem identified in the HPI

An Extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.

A Complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. 

• The Provider must individually document those systems with positive or pertinent negative responses. 

• For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems.

Past, Family, and/or Social History (PFSH)

PFSH consists of a review of three areas,

1. Past history includes experiences with illnesses, operations, injuries, and treatments

2. Family history includes a review of medical events, diseases, and hereditary conditions that may place the patient at risk

3. Social history includes an age-appropriate review of past and current activities

The two types of PFSH are pertinent and complete

A Pertinent PFSH is a review of the history areas directly related to the problem(s) identified in the HPI. 

The pertinent PFSH must document at least one item from any of the three history areas.

A Complete PFSH is a review of two or all three of the areas, depending on the category of E/M service. 

A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient. 

For Details of MDM 

Office-Based Opioid Use Disorder (OUD) Treatment Billing

The CMS included new coding and payment for a monthly bundle of services for the treatment of (Opioid Use Disorder) OUD that includes,

• Overall management
• Care coordination
• Individual and group psychotherapy
• Substance use counseling
• Add-on code for additional counseling

The provider to bill for a group of services in the office setting similar to the services covered under the Opioid Treatment Program benefit for clinics.  

Clinicians providing these bundled services to Medicare patients should use these codes,

G2086 - In the first calendar month,

• Developed the treatment plan
• Coordinated care
• Provided at least 70 minutes of individual therapy and group therapy and counseling

G2087 - In a subsequent calendar month,

• Coordinated care
• Provided at least 60 minutes of individual therapy and group therapy and counseling

G2088 -  In a subsequent calendar month,

• Coordinated care
• Provided more than 120 minutes of therapy and counseling
• Note: Bill each additional 30 minutes separately and include the code for the primary procedure
• CPT G2088 add-on code to be reported with CPT G2087

Tips

• G2086 to report the development of a  treatment plan, care coordination, and counseling of at least 70 minutes in the first calendar month

• G2087 to report treatment, care coordination, and counseling of at least 60 minutes after the first month, 

• G2088 for each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure).