Medicare has changed its policy on EM service documentation provided by Medical Students. Implementation date is 3-5-18 Change request 10412.
Previously the physician could only use the ROS and PMSFH from a medical students document, the change is that teaching physician can use their documentation, they must verify all the students documentation. The teaching physician must personally perform the physical exam and medical decision making activities, you do not have to re do the documentation of the medical students note but must confirm that you personally performed these aspects.
- The attending physician must be at the bedside while the student performs any of the E/M elements.
- The attending physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed.
- The attending physician may verify student documentation of any or all E/M elements in the medical record, rather than re-documenting information that has already been documented.
- Attestations to confirm the presence and performance of the necessary elements should be documented by the attending physician.
Do not apply your usual resident/fellow attestation, there would have to be a new created to ensure that the points above are covered especially that elements that your personally performed.
Moderate (Conscious) Sedation
You are now permitted to bill separately.
99152 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
99153 Each additional 15 minutes
99156 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older
99157 Each additional 15 minutes
Pre service (do not include in time)
- Assessment/Documenting PMFS history regarding sedation or anesthesia and drug allergies
- Summary of meds list
- Exam of Vitals, Airway, Chest, Lungs, Heart and circulation
- Completion of pre sedation assessment form that includes the ASA physical status classification.
Intraservice (Timing begins)
- Timing begins when sedation started and ends the patient is stable for recovery status.
- Administering initial and subsequent doses (type and amount)
- Continuous face to face attendance
- Documenting periodic assessment, O2 sats, heart rate and BP
Post service (do not include in time)
- Post sedation assessment, Vitals, CV and pulmonary stability, level of consciousness.
- Discharge readiness and family updates
Bronchoscopy- wRVU (reimbursement) was deceased because CPT/AMA/CMS have unbundled the moderate sedation work from these codes.
You can be billed with Critical Care, Emergency medicine and Initial Visit codes just the same as other procedures, the visit encounters are separately and identifiable evaluation and management services.
You cannot bill them on the same day with a subsequent visit or observation visit
Approximate Medicare reimbursement
99152 $12.22 MS same provider with independent observer
99156 $75.00 MS with different performing provider
End of Life discussions
Advance care planning face to face service with the patient, family member, or surrogate discussing advance directive with or without completing relevant legal forms. The advanced directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at the time. When using 99497 99498 no active management of the problems is undertaken during the time period report.
Voluntary advance care planning means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.
Not reportable with 99291 on the same day but they can be used with other evaluation and management codes. It should be a separate encounter note when bill with a medical service (EM) code on the same day.
When the patient is critically ill and the decision to withdrawal or initiate treatment is being determined that critical care is billed.
Medicare does not have any specific documentation requirements on it yet. However, since it is a timed code; the time spent would have to documented, who was involved in the discussion and as well as what conditions are warranting the discussion, the management options of the condition(s) that were discussed and what the outcome(s) decision are.
Some Medicare carriers allow for the guideline from the CPT manual of ½ time to meet the thresholds
Critical Care and Telehealth
Medicare now has HCPCS codes for Telehealth Critical Care
G0508 - Telehealth Critical Care initial, physician typically spends 60 minutes communicating with the patient and providers via telehealth.
G0509 - Telehealth Critical Care subsequent, physician typically spends 50 minutes communicating with the patient and providers via telehealth.
The GT modifier will need applied to telehealth codes.
You must verify that the originating site is a facility in HRSA area.