Evaluation and Management Help Center

Published 12/20/2023

The CY2022 the Centers for Medicare & Medicaid Services (CMS) guidance regarding Split/Shared, Critical Care and other services is located in the following CMS publications:

Palmetto GBA is in the process of updating our web education related to these services based on the CMS guidelines and will notify our provider community through the jurisdictional websites and our Email Updates messaging. Please review the articles above for full details.

In the inpatient hospital setting, all physicians and qualified nonphysician practitioners (where permitted) who perform an initial evaluation visit may bill initial hospital care CPT® codes (99221–99223) or nursing facility care CPT® codes (99304–99306).

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.1.G (PDF).

Last Reviewed: 12/20/2023

Yes, subsequent hospital CPT® codes (99231–99233) can be submitted in place of initial hospital CPT® codes (99221–99223) if the minimum key component work and/or medical necessity requirements for initial care services are not met.

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claims Processing Manual, Chapter 12 (PDF), Section 30.6.9.1.F.

Last Reviewed: 12/20/2023

Yes. Hospital and nursing facility discharge services are time-based; codes are utilized to show the total duration of time that a physician or qualified health professional spent to discharge a patient. Time must be documented in the patient’s medical record to support the level of service billed.

Example
CPT® code 99239 is billed. The patient’s discharge notes states "45 minutes of time spent performing discharge services." The documentation supports the provider billing CPT® code 99239 as more than 30 minutes of hospital discharge time is reported.

Hospital Discharge Codes

CPT® Code
Code Description
99238
Hospital discharge day management, 30 minutes or less
99239
Hospital discharge day management, more than 30 minutes

Nursing Facility Discharge Codes

CPT® Code
Code Description
99315
Nursing facility discharge management; 30 minutes or less
99316
Nursing facility discharge management; more than 30 minutes

Last Reviewed: 12/20/2023

Medicare pays for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his or her observation care. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8 (PDF).

Last Reviewed: 12/20/2023

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 physician 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. 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.

If the ED physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.

Resource: CMS Internet-Only Manual (IOM) Pub 100-04, Medicare Claim Processing Manual, Chapter 12, Section 30.6.11 E and F (PDF).

Last Reviewed: 12/20/2023

"New patient" means a patient who has not received any professional services, such as an 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 three years. For example, if a professional component of a previous procedure is billed in a three year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed), then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test (reading an X-ray or EKG, etc.) in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Reference: CMS Internet-Only Manual (IOM) Medicare Claims Processing Manual (PDF), Chapter 12, Section 30.6.7 .

Last Reviewed: 12/20/2023


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