Grace: Hi Becky, welcome. Thank you for joining me today.

Becky: Thank you, Grace.

Grace: Many of our listeners are likely familiar with the term evaluation and management, or E/M. But for anyone new to this subject, could you give us a little background on what E/M is?

Becky: Sure can. Evaluation and management services are utilized for problem focused visits performed in all healthcare settings. These are cognitive services in which a physician or other qualified healthcare professional, which I’ll refer to as QHP throughout our podcast today, that is where they diagnose and treat illnesses or injuries.

Code selection in most of our categories of E/Ms are based on either time or medical decision making. It is truly important for providers, coders, auditors, educators and template developers to understand the E/M guidelines to maintain compliance with coding and documentation.

Grace: We’ll dive deeper into these in a moment, but could you give us an overview of the key changes to E/M guidelines in 2024?

Becky: Sure. I picked up just a few of them that are out there. There’s much more, some new codes that are out there as well that will be interesting as we move forward.

But broadly, the following areas we have are: Shared or split care visits, those have been changed; multiple E/M services on the same date of service; they gave us some instructions on the proper use of hospital, inpatient or observation services, which do include our same day admit discharge codes 99234 through 99236; and there’s a new G-code for CMS out there for evaluation and management visits that are part of an ongoing longitudinal care relationship. Those are gaining quite a bit of interest and attention.

One of the things to mention is, as we typically encounter, CMS (the Centers for Medicare and Medicaid Services) as well as the American Medical Association (AMA) do not have the same guidelines for some of these changes. So, we always need to be looking at our carriers and how we need to code for those services rendered.

Grace: I see. That must add an additional layer of complexity to these.

Becky: It sure does.

Grace: Let’s focus in on split/shared visits first. First of all, for anyone unfamiliar with this term, could you tell us how split/shared visits are defined?

Becky: Yes, a split/shared visit is when services are provided jointly between a physician and a non-physician provider who both work in the same group and same specialty. So non-physician providers are typically our PAs or our NPs.

You do have to note that AMA guidelines indicate that when [an] advanced practice nurse and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. However, CMS has indicated they will continue to not recognize subspecialties for defining initial versus subsequent services. And what that means is they do not allow providers in the same specialty but different subspecialties to report separate initial visits.

Also, with shared/split care services, the two providers may act as a team in providing care to the patient in the hospital and other institutional settings, working together during a single E/M service. The shared/split care guidelines are applied to determine which professional reports the service.

If you picked up, I stressed institutional settings are where shared/split care services are rendered; [whereas] in the clinic setting, which is typically place of service 11, incident two is followed versus shared/split care guidelines. So now we have to dive into place of service as well.

Grace: Okay, thanks for that background. So, what are the key changes affecting split/shared visits in 2024?

Becky: Okay, so let’s talk about the guidelines. Both AMA and CMS instruct to utilize either time or medical decision making to determine the substantive portion of the visit. The provider who performs that substantive portion of the encounter is the one who would report the service. Now, I feel that time is the easier way to determine the billing provider. However, in discussion with clinicians, the overall consensus is that medical decision making is actually the more relevant area.

So, let’s talk about time. That’s the easier way if both providers for shared/split care services must document their time and the level of service is based on the total time spent by both of those providers on that date of the encounter.

The billing provider is the professional who spent the majority of the non-face-to-face or face-to-face time performing the service. You have to always remember that, when calculating time with two providers involved, only distinct time can be utilized. So, if those providers are meeting with the patient together, only one of them can report the time.

I think documentation best practice is to document the start and stop times for each of the providers so that no overlapping time is summed to determine that level of service.

Jumping into the medical decision making area. Little bit of difference here again in the guidelines.

AMA requires that the physician or other QHP made or approved the management plan for the number and complexity of problems addressed at the encounter and that they take responsibility for that plan with its inherent risk of complications and or mortality or morbidity of patient management.

Now, let’s go over to CMS. They are a little stricter than AMA, so CMS indicates that there needs to be a little bit more.

CPT allows that physician to merely review the NPP’s note and add his or her signature to show he or she agrees with the NPP. CMS expects that the medical record would contain sufficient documentation to show which provider performed the medical decision making portion of the visit.

What that means as a whole is that a physician’s signature on its own is likely not enough to support billing under the physician for that split/shared care visit. So, the recommendation here would be to put a policy in place for your facility. If you’re doing a lot of these shared/split care services, you want to ensure that providers understand there’s a difference between AMA and CMS as well.

Also, CPT Symposium—always attend it every year, highly recommend it—the CPT panel determined that they were going to give a little more guidance with the hopes that CMS would adopt this guidance in 2025. What they say is, a physician or other qualified healthcare professional has performed two of the three elements used in the selection of the code level based on medical decision making.

So, remember, we have three areas for medical decision making.

If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported level of service, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by that physician or other QHP. They say that this is because the relevant items would be considered in formulating the management plan, so don’t need to personally perform those in order to be the billing provider. However, independent interpretation of tests and discussion of the management plan or a test interpretation must be personally performed by the physician or other QHP if that is used to determine the level of service.

So, what they’re saying here is, if there is an independent interpretation of a test and discussion of the management plan, or a test interpretation, that has to be personally performed by the billing provider.

The provider who bills the split/shared care visit has to sign and date the medical record. However, I want to put a best practice in here. We always say, when you document you sign, so I would recommend that both providers sign and date the note.

One last comment: CMS does require modifier FS on all shared/split care visits.

Keep in mind, when we have a new modifier, it’s probably going to be watched and monitored and there probably will end up being some type of OIG RAC audit review on those. So, always keep that in the back of your mind.

Grace: Perfect. And you mentioned multiple E/M services on the same date as a category affected by the E/M guidelines updates. Let’s dive into this next. What do these changes look like?

Becky: This is interesting. Again, we have a difference between AMA and CMS.

AMA does allow reporting two services by the same practitioner on the same date of another E/M service, whereas CMS does not.

So, we’re going to talk about CPT guidelines. A patient may receive E/M services in the same or more than one setting on a calendar date. There are circumstances in which the patient has received multiple visits or services from the same physician or other QHP or another physician or other QHP of the exact same specialty and subspecialty—remember, this is CPT—who belongs to the same group practice. The hospital, inpatient and observation care services and nursing facility services are per day services. So, when multiple visits occur over the course of that single calendar date in that same setting, you only still report one service code.

When using medical decision making for that code level selection, we would aggregate that medical decision making over the course of that entire calendar date, and for time, we would sum the time over the course of the day using the guidelines for reporting time.

If we have multiple encounters in different settings or facilities—that is, the patient can be seen and treated in different facilities so they can go hospital to hospital transfer, for an example—when more than one primary E/M service is reported and time is used to select that level, only the time spent providing that individual service can be allocated to the code selection. You cannot count time twice when reporting more than one E/M service, so no overlapping here.

For prolonged services, those are also based on the same allocation and their relationship to the primary service. The designation of the facility may be defined by licensure or regulation. So, this is a very important factor to know prior to coding for those two E/Ms on the same date of service.

If you transfer a patient from a hospital bed to a nursing facility bed in a hospital with those types of nursing facility beds, that is considered two services in two facilities because you are discharging the patient from hospital over to nursing facility

An intra-facility transfer, for a different level of care—so, if you’re moving a patient from a regular unit to a critical care unit—that does not constitute a new stay. That patient is just moving within that same facility.

In the emergency department or services in other settings that can be in the same or different facilities, the time spent in the emergency department by a physician or other QHP who provides a subsequent E/M service can be used in calculating total time on that date of service when they are not reporting the ED service and the other E/M service is reported. Always keep in mind: there are no time components that are included in the descriptor of the emergency department codes.

For discharge services and services, and other facilities, each service may be reported separately as long as the time spent on discharge is not counted towards the other level of service for the subsequent service. So, you can’t double dip on your time here. This also includes any hospital, inpatient, or observation care services including those same day admit and discharge codes, because those services are also selected based on medical decision making or time. When those services are reported with another E/M on the same calendar date, time related to the hospital inpatient or observation care service cannot be used for code selection of the subsequent service.

For discharge services and services in the same facility, if the patient is discharged and readmitted on the same calendar date to the same facility, you would report a subsequent care code instead of a discharge or an initial service. For the purposes of E/M reporting, that is considered a single stay.

If you have discharge services and services in a different facility—so, if the patient is discharged from one facility and then admitted to another—that is considered a different stay. Therefore, the discharge and the initial service can be reported as long as time spent on the discharge service is not counted towards the total time of the initial when reported based on time.

Transitions between office or other outpatient, home or residence or emergency department and hospital, inpatient or observation or nursing facility—so, quite a large gamut of categories there—if that patient is seen in two settings and only one service is reported, the total time on the date of the encounter or the aggregated medical decision making is used to determine the level of service, and you would only report one E/M code.

So, a lot of information there. Remember, those are all AMA CPT directives.

Grace: So, between the split shared guidelines and the multiple visits on the same day, it seems like there’s a common theme of clarifying guidelines to avoid, as you said, accidentally double dipping when determining and reporting level of service. Is that fair to say?

Becky: Yes, that is very true.

Grace: Got it. All right, we can move on to the next topic. Proper use of hospital, inpatient or observation services, including admission and discharge. So, this encompasses CPT codes 99234 to 99236. What are the important changes to note here?

Becky: So, the goal of these updates is to provide direction on the appropriate use or label of certain types of services for coding and create consistency with CMS, particularly addressing those short stays that are less than 8 hours. There is a very nice table that was provided regarding these and how they want us to look at these.

So, if the patient’s length of stay—let’s say they’re placed either inpatient or observation, that’s exactly what we’re talking about here—if the length of stay is less than 8 hours, you are to be reporting the initial codes only.

So, less than 8 hours, you would not report an admit and discharge or a same day admit discharge, which is 99234 through 99236. Now, if the stay is 8 hours or more on the same calendar date, that is where you would use your same day admit discharge codes.

Keep in mind, those 99234 through 99236 codes are used only by the physician or other QHP who performed both the initial and the discharge services. Any other providers would be reporting initial codes

And then, you know, the same follows through, this has not changed. If it’s less than 8 hours and there’s a different calendar date, you day one would report your initial codes, and then your subsequents in between there, and then your discharge codes in there.

There were also some minor language changes. The guidelines for those same day admit discharge codes replace the word “encounter” with “visit” to clarify that these codes apply only when two separate visits—one initial admission and one discharge service—occur on the same day.

Grace: I see. Let’s move on to the new G-code. What can you tell us about this change?

Becky: All right. So, the G-code G2211 is an add-on code that is applicable only to office or other outpatient visit codes. It reflects the time, intensity and practice expense resources involved with physicians who provide these services that build longitudinal relationships with the patient and address the majority of the patient’s health care needs with consistency and continuity over longer periods of time.

When you think about that descriptor of the code, it is typically part of primary care services or internal medicine, but they are not limiting it to the type of provider who can report it. You just need to ensure that your treatment of that patient is actually addressing the majority of the patient’s health care needs and it’s over a longer period of time. So, it’s really that relationship status that we’re looking for.

One would use this code when the provider is the continuing focal point for all healthcare services the patient needs. CMS does indicate the relationship between the patient and the physician is the determining factor of when to add this code.

One little note here: You cannot use G2211 when the E/M service has modifier 25 appended to it or with 99211, which technically we define as a nurse visit.

So, for a little bit of background on this code. The studies were showing that primary care office visits were more complex than those that were conducted by other specialties. Primary care physicians can pack highly complex care into very short visits by managing all of the patient’s acute and chronic conditions, providing ongoing preventive services and counseling, and addressing behavioral health challenges and unmet social needs. So, they developed this code to cover that additional practice expense and time and the expertise for that G2211.

Medicare officials agreed that the updated office visit E/M payments don’t fully account for the more complex whole person care that is being provided by primary care physicians. Existing coding processes are better at denoting procedures than at describing cognitive services such as continuous comprehensive primary care.

Our current coding for E/M services fails to account for many of the unique services and resources that primary care physicians provide or reflect their extraordinary role in coordinating care for their patients. When you think about this, the typical primary care physician caring for Medicare patients must coordinate care, and this is on average, with 229 other physicians working in 117 practices. That’s a lot of work. And so that is where this G-code is meant to capture that and give additional payment for that work.

Grace: That’s so interesting. That seems like a really great illustrator of the constantly evolving nature of these guidelines to meet the real-world needs of that setting.

Becky: Exactly.

Grace: So, are there any other guideline updates that our listeners should be aware of?

Becky: Well, I could talk about updates to codes and guidelines for days on end. I’m going to try to choose those that are related to the E/M, seeing as that’s our topic today.

So, CPT did make two clarifications regarding data in medical decision making. I have to say, in my own personal opinion, data has gotten to be so confusing. [We are] finding ourselves digging back in the medical records to appropriately determine, can we give credit for this, can we not give credit for this? So, it is getting to be quite tedious and mundane for review purposes

For CPT, one of the items that they clarified was tests ordered and independently interpreted. First, the definition of an independent interpretation: That independent interpretation of a test for which there is a CPT code that can be billed, and an interpretation or report, is a customary part of that test. You cannot give credits when the physician or other QHP who reports the E/M is reporting the CPT code for that diagnostic test or has previously reported the test.

So, if you’re billing for the interpretation and report, of course you can’t take credit for that in the E/M. If they’ve previously reported the test, it’s a one and done for data. Once you look at it, you’re done. You can’t take credit for it again, that being the same provider or QHP in the same specialty or subspecialty.  So, some type of interpretation has to be documented, but it doesn’t need to conform to the standards of that complete report. A test that is ordered and independently interpreted may count as both a test ordered and interpreted.

Our second clarification was for an appropriate source. For the purpose of the discussion of management data, an appropriate source includes professionals who are not healthcare professionals, but they may be involved in the management of the patient. So, this could be a case manager, a teacher, a lawyer, a parole officer. It does not include discussion with the family or caregivers. And they also said, for documents that are reviewed, documents from an appropriate source may be counted towards data.

There are quite a few other clarifications provided by AMA. I’m going to briefly touch on those.

So, regarding the number and complexity of problems addressed at the encounter, which is one element utilized in selecting the level of service, AMA indicated multiple new or established conditions may be addressed at the same time and may affect medical decision making.

Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities and underlying medical conditions in and of themselves are not considered in selecting a level of service of E/M unless they are addressed and their presence increases the amount and or complexity of data to be reviewed and analyzed or the risk of complications and or morbidity or mortality of patient management.

Here’s an important clarification. The final diagnosis for a condition does not in and of itself determine the complexity or risk as an extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. So, presenting symptoms that are likely to represent a highly morbid condition may drive medical decision making even when the final diagnosis is not highly morbid.

I know from my time consulting, which is a really long time, you can’t look at the final diagnosis. You have to look at how that patient presents and all the work that is done in order to come up with that final diagnosis and treatment plan. So, it’s not based on your final diagnosis and we always need to remember that.

Another clarification was regarding risk. AMA clarified that management risk is different than condition risk. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.

Talking about management risk, AMA also clarified parental controlled substances indicating that the level of risk is based on the usual behavior and thought process of a physician or other QHP in the same specialty and subspecialty and not simply based on the presence of an order for that controlled substance. So, keep that in mind.

One last item. Talking about hospital inpatient or observation care services, AMA did talk about when those services continuously span two calendar dates, meaning that they cross that midnight threshold. AMA clarified that in this circumstance, you report a single service and report that service on one calendar date. If that service is continuous before and through midnight, all the time can be applied if you’re utilizing time for your level of service.

CPT doesn’t provide instructions on what data services reported. However, CMS did indicate that you would report the date the patient encounter begins. So, again, no directive versus some directive from CMS. So, you need to determine what you’re going to do with that internally.

Grace: Got it. So, we’ve covered a lot of ground in this episode. Just to zoom out for a moment, could you speak to what are some of the common errors that you see in E/M coding? And do you believe that these guideline updates will help resolve these problems?

Becky: So, common errors. The documentation is really important. And you know, often times, I have providers that say to me if I do this and this, that’s a four, right? Well, no, I really need to see the documentation, and one of the things that typically we see lacking is the medical decision making process.

This really is the thought process of the provider and the work that they did, and we need to try to get that on the paper, which is very hard for providers to do because nine times out of ten it is a manual data entry process.

So, those providers should be educated on how to appropriately document the medical decision making process within their assessment and plan, preferably.

The guidelines themselves do clarify some frequently asked questions; however, from a documentation perspective it’s not really going to solve any problems. We still need more work and education in order to get our documentation up to where it needs to be for our levels of service.

One other thing that I have to mention that was discussed at Symposium—and this was during a Q&A session, so of course it’s not written, it was verbally said, and unless somebody transcribed that conversation, we’re probably not going to have it there. But what they said was, we are not to utilize the old table of risk. When you look at the way the new guidelines are laid out, they only give us a few examples of moderate and high risk.

I really, truly recommend that providers document the level of risk—they are the ones who know their patients best—and then add a statement indicating why the patient falls into that category of risk.

Grace: Would you say that your background as a nurse informs how you understand and educate others about E/M guidelines?

Becky: It certainly does. While I’m auditing documentation and looking to ensure that everything is supported appropriately, I have to take off my nurse hat so that I don’t make assumptions.

The nice thing about having a nursing background and still actively participating in nursing, I’m able to discuss disease processes, possible management options and treatments to help the providers document their thought process to aid in supporting medical decision making. It helps them sometimes if I can throw out a couple of ideas—”did you think about this? Did you think about that?” They’re like, well, yeah, of course I did, and I’m like, but it’s not documented.

So, kind of triggering some of their thought processes to get that down on paper is very helpful.

My nursing background also aids in assisting with template development to help insert some reminders into those templates for the sole purpose of documentation. So, just giving them those little keywords or asking them a little question within their templates actually helps drive them to document more of their thought process in the end.

Grace: What can our listeners do to make sure that they’re working with the most up to date guidelines? Do you have any resources you’d recommend to a coding professional looking to learn more about this topic?

Becky: I would recommend that you ensure providers, coders, auditors and templates are updated. I have to say, it is nearly impossible to grasp all of the changes throughout the entire CPT book simultaneously.

You also want to ensure that any vendors and any software that you utilize is up to date to make sure that you’re ensuring compliance on your end.

Panacea does always recommend a proactive approach when it comes to coding proficiency. This includes actively pursuing educational programming and conducting regular internal audits to identify those recurring errors. Audits and education are just two of Panacea’s offerings and two of my favorites.

Grace: So, there you have it. Those are some of the primary updates to E/M that we’ve seen in 2024. Today we talked about split/shared visits, multiple E/M services on the same date, and the proper use of hospital inpatient or observation services, including admission and discharge services, for codes 99234 to 99236, as well as the new G-code, G-2211, and a handful of clarifications affecting medical decision making and risk.

Thank you so much, Becky, for joining me and sharing your expertise.

Becky: Thank you, Grace. My pleasure.

Grace: And to our listeners, thank you for joining us today for our conversation. I hope you learned something new to take with you. If you have any questions or want to continue the conversation, please visit our website or reach out to us on social media. If you’d like more info about anything you’ve heard today, you can contact us at contact@panaceainc.com.

Stay tuned for more thought-provoking episodes on 1st Talk Compliance. Until next time, take care and stay informed.