Modifier 25:
· AMA Rules– “Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same day.”
· CMS Rules– “Don’t bill the previous encounter.” The existing CMS rule 100-04, Chapter 23 30.6.9.1A states “When a patient is admitted to the hospital from another site of service, including the office, emergency department nursing facility, those services are part of the initial hospital inpatient or observation visit."
Reporting Initial Visit:
· AMA Rules – “Any physician or qualified health care professional can report an initial visit if they ---or someone from their group who is of the same specialty and subspecialty – have not performed a professional service for the patient during their stay in the hospital or nursing facility."
· CMS Rules – “Medicare specifies that for observation care for a patient may bill for observation other practitioners providing additional evaluations for the patient bill theirs as (office/other outpatient) E/M codes”
· CMS Rules - A reminder: the Medicare rule for requirement of AI (Principal physician of record) policy has not changed.
· “(Rev. 11288; Issued: 03-04-22; Effective: 01-01-22; Implementation: 02-15-22) “The principal physician of record must append the modifier “-AI”, (Principal Physician of Record), to the initial nursing facility care code. This modifier will identify the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. All other physicians or qualified NPPs who perform an initial evaluation in the NF or SNF may bill the initial nursing facility care code. The initial federally mandated visit is defined in S&C-04-08 (see http://www.cms.gov/sitesearch/search-results.html?q=S%26C-04-08) as the initial comprehensive visit during which the physician completes a thorough assessment, develops a plan of care, and writes or verifies admitting orders for the nursing facility resident.”
How to code prolonged services:
· AMA Rules – “You can report a prolonged service on the same day as the face-to-face encounter with 99417 for visits in the office/outpatient and home/residence settings or 99418 for visits in the hospital or nursing facility settings.”
· CMS Rules - CMS created three new prolonged service codes: G0316, G0318, and G2212 to go with office/other outpatient prolonged services codes. Be careful, there have been corrections for these G codes with time lines identified.