Indiana Osteopathic Association
116th Annual Convention
May 4, 2013
Presented by
Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
5725 Park Plaza Court
Indianapolis, IN 46220
Voice: 317.573.3960
Fax: 866-631-9310
E-mail: help@joynewby.net
This presentation was current at the time it was published and is intended to provide
useful information in regard to the subject matter covered.
Newby Consulting, Inc. believes the information is as authoritative and accurate as is
reasonably possible and that the sources of information used in preparation of the
manual are reliable, but no assurance or warranty of completeness or accuracy is
intended or given, and all warranties of any type are disclaimed.
The information contained in this presentation is a general summary that explains
certain aspects of the Medicare Program, but is not a legal document. The official
Medicare Program provisions are contained in the relevant laws, regulations, and
rulings.
Any five-digit numeric Physician's Current Procedural Terminology, Fourth Edition
(CPT) codes service descriptions, instructions, and/or guidelines are copyright 2012 (or
such other date of publication of CPT as defined in the federal copyright laws)
American Medical Association.
For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and
service/procedure descriptions to be used in this presentation.
The American Medical Association assumes no responsibility for the consequences
attributable to or related to any use or interpretation of any information or views
contained in or not contained in this publication.

On January 2nd, President Obama signed the
American Taxpayer Relief Act of 2012
◦ Replaced the 26.5 percent decrease with a 0.0 percent
update in the conversion factor
◦ Dates of service 1/1/2013 – 12/31/2013

Fee Schedule will have changes from 2012
◦ Budget neutrality factor required reduction in conversion
factor from $34.0376 to $34.0230
◦ Changes in relative value units

Fee Schedule is posted on Indiana Medicare
website
4

2% reduction applies to all original Medicare
payments
◦ Applies to all payments made by original
Medicare (includes injectable drugs and supplies)
◦ Effective with dates of service on and after April 1,
2013
◦ Without Congressional action, effective for the rest
of 2013
◦ Claim adjustment reason code (CARC) 223 is used
to report the sequestration reduction on EOBs
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
5
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Commercial payers
Department of Justice (DOJ)
Office of Inspector General (OIG)
Zone Program Integrity Contractors (ZPIC)
Medicare Administrative Contractors (MAC)
Comprehensive Error Rate Testing Contractor (CERT)
Medicare and Medicaid Recovery Audit Contractors
(RAC)
Medicaid Integrity Contractors (MIC)
Medicaid Payment Contractors
6

On February 11, 2013, Attorney General Eric Holder and
Health and Human Services (HHS) Secretary Kathleen
Sebelius released a report showing that for every dollar
spent on health care-related fraud and abuse
investigations in the last three years, the government
recovered $7.90.
◦ This is the highest three-year average return on
investment in the 16-year history of the Health Care
Fraud and Abuse (HCFAC) Program.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
7
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Morton Plant Mease Health Care Inc. and its affiliated hospitals
(Morton Plant) have agreed to pay $10,169,114 to the federal
government to resolve allegations that they violated the False Claims
Act by submitting false claims for services rendered to Medicare
patients
◦ Morton Plant owns and operates, or is affiliated with, Morton Plant Hospital, St.
Joseph’s Hospital, Morton Plant North Bay Hospital, St. Anthony’s Hospital,
Mease Countryside Hospital and Mease Dunedin Hospital. These hospitals are
part of the BayCare Health System in Florida’s Pinellas, Hillsborough and Pasco
counties.
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The settlement announced resolves allegations that, between July 1,
2006 and July 31, 2008, Morton Plant improperly billed for certain
interventional cardiac and vascular procedures as inpatient care when
those services should have been billed as less costly outpatient care or
as observational status
Whistleblower will receive over $1.8 million as her share of the
government’s recovery
8

Georgia Cancer Specialists, PC agreed to pay $4.1 million to
settle claims that it violated the False Claims Act by billing
Medicare for evaluation and management services that were
not permitted by Medicare rules.
◦ Georgia Cancer Specialists is one of the largest private
oncology practices in the country with 27 offices located
throughout the Atlanta metro area.

The settlement announced resolves allegations related to the
billing for E/M services on the same day as a related
procedure (probably chemotherapy)
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U.S. Attorney’s Office alleged that Georgia Cancer Specialists
applied modifier -25 to claims that did not qualify for its use,
leading to overpayments by Medicare
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
9
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American Sleep, headquartered in Jacksonville, Fla., owns
and operates 19 diagnostic sleep testing centers throughout
the United States, including in Alabama, California,
Delaware, Florida, Illinois, Indiana, Kansas, Kentucky,
Maryland, Missouri, New Jersey, Tennessee, Texas, and
Virginia.

The United States contended that American Sleep submitted
false claims to Medicare and TRICARE between Jan. 1, 2004,
and Dec. 31, 2011 because the diagnostic testing services were
performed by technicians who lacked the required credentials
or certifications, when it knew this violated the law.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
10
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Between 2002 and the end of September 2012
Medicare, Medicaid, and numerous private insurers
“…it would have been impossible for any physician to
provide the medical treatment to that number of
patients in a single day. “
◦ November 29, 2007, February 20, 2008, and June 19,
2008
◦ Provided services to 82, 85, and 92 patients, and the
aggregate “typical” time component associated with
the codes submitted for payment were 30 hours, 35
hours, and 40 hours, respectively.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
11
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Settlement resolves the government’s allegations that between
2001 and 2006 EMH and NOHC performed unnecessary
cardiac procedures on Medicare patients.
◦ Specifically, the United States alleged that EMH and NOHC
performed angioplasty and stent placement procedures on
patients who had heart disease but whose blood vessels
were not sufficiently occluded to require the particular
procedures at issue

Whistleblower will receive $660,859 of the United States’
recovery
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
12
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CMS approved limited review, statistical sampling of
evaluation and management claims to calculate and project
incorrectly paid claims
Connelly, Inc. the Region C Recovery Audit Contractor,
◦ RAC Region C includes Alabama, Arkansas, Colorado,
Florida, Georgia, Louisiana, Mississippi, New Mexico,
North Carolina, Oklahoma, South Carolina, Tennessee,
Texas, Virginia, West Virginia, Puerto Rico, and the US
Virgin Islands.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
13
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Medical necessity is the overall criterion for payment in
addition to the specific technical requirements of a CPT
code
It is not appropriate to bill a higher level of E/M service
when a lower level of service is warranted
The volume of documentation should not be used to
determine the level of service
Services billed should be individualized to the
presenting problem(s) on the date in question.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
14
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Providers should be aware that templates designed to
gather selected information focused primarily for
reimbursement purposes are often insufficient to
demonstrate that all coverage and coding requirements
are met
Beware of templates that overestimate decision-making.
Understand the logic of templates and/or computer
programs used for E/M service coding.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
15
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Coverage defined by:
Title XVIII of the Social Security Act, Section 1862
(a)(1)(A). This section allows coverage and payment for
only those services considered medically reasonable and
necessary for the diagnosis or treatment of illness or
injury or to improve the functioning of a malformed
body member.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
16
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Identify all the presenting complaint(s) and/or reason(s)
for the visit for which physician work occurred.
◦ Demonstrate clearly the history, physical and extent of
medical decision-making associated with each
problem.
◦ Demonstrate clearly how physician work (expressed
in terms of mental effort, physical effort, time spent
and risk to the patient) was affected by comorbidities
or chronic problems listed.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
17
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Physician Regulatory Issues Team (PRIT)
◦ Surgeons routinely provide focused H&Ps to their surgical
patients as part of the preoperative services which are
bundled into the payment for the surgery.
◦ Patients who have significant comorbid conditions may
require a preoperative visit with an internist or
subspecialist in which case that visit would be covered.
 It would be appropriate for the internist to perform a
focused H&P and make recommendations concerning the
management of the patient’s comorbid conditions during
the preoperative period.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
18
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Medical necessity rules apply
Not an admission/facility history and physical
◦ Surgeon’s global surgical package includes the problemfocused admission/facility H&P
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Must be requested by the surgeon
◦ Request must state medical problems needing evaluation to
determine patient’s risk of perioperative complications and
for optimizing perioperative care
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Report must be issued stating whether patient is cleared
for surgery, additional work-up needed
recommendation not to proceed with surgery, etc.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
19
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Preoperative Diagnostic Tests
◦ Defined as tests performed to determine a patient’s
perioperative risk and optimize perioperative care
Preoperative diagnostic tests are payable if they are
medically necessary and meet any other applicable
requirements
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
20
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All claims for preoperative medical examination
and preoperative diagnostic tests (i.e., preoperative
medical evaluations) must be accompanied by the
appropriate ICD-9 code for preoperative
examination (e.g., V72.81 through V72.84)

Additional appropriate ICD-9 codes for the
condition(s) that prompted surgery

Additional appropriate ICD-9 codes for conditions
that prompted the preoperative medical evaluation
(if any), should also be documented on the claim
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
21
 2013
Work Plan
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
22
The OIG will review Medicare payments for high-cost
diagnostic radiology tests to determine whether they were
medically necessary and the extent to which the same
diagnostic tests are ordered for a beneficiary by primary
care physicians and physician specialists for the same
treatment.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
23
The OIG will review physician billing for “incident-to”
services to determine whether payment for such services
had a higher error rate than that for non-incident-to
services.
 They will also assess Medicare’s ability to monitor
services billed as “incident-to.” Medicare Part B pays for
certain services billed by physicians that are performed
by nonphysicians incident to a physician office visit.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
24
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After it self-disclosed conduct to the OIG, Bartlett
Regional Hospital (Bartlett), Arkansas, agreed to
pay $1,434,664.50 for allegedly violating the Civil
Monetary Penalties Law.
The OIG alleged that Bartlett submitted claims
using incorrect physician names and NPI numbers
and submitted claims for non-physician provider
services that were billed under a physician's name
and NPI number.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
25
The OIG will describe billing characteristics for Part B
clinical laboratory tests in 2010. They will also identify
questionable billing for Part B clinical laboratory tests in
2010.
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In 2008, Medicare paid about $7 billion for clinical laboratory
services, which represents a 92-percent increase from 1998.
Much of the growth in laboratory spending was the result of
increased volume of ordered services.
Medicare pays only for those laboratory tests that are ordered
by a physician or qualified nonphysician practitioner who is
treating a beneficiary.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
26
The OIG will review Medicare contractors’ procedures for
screening the frequency of clinical laboratory claims for
glycated hemoglobin A1C tests and determine the
appropriateness of Medicare payments for these tests.
 It is not considered reasonable and necessary to perform
a glycated hemoglobin test more often than every 3
months on a controlled diabetic patient unless
documentation supports the medical necessity of testing
in excess of national coverage determinations guidelines.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
27
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The OIG will determine the extent to which CMS made
potentially inappropriate payments for E/M services in 2010
and the consistency of E/M medical review determinations.
They will also review multiple E/M services for the same
providers and beneficiaries to identify electronic health
records (EHR) documentation practices associated with
potentially improper payments.
◦ Medicare contractors have noted an increased frequency of
medical records with identical documentation across
services.
◦ Medicare requires providers to select the code for the
service on the basis of the content of the service and have
documentation to support the level of service reported.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
28
The OIG will review the appropriateness of the use of certain
claims modifier codes during the global surgery period and
determine whether Medicare payments for claims with
modifiers used during such a period were in accordance with
Medicare requirements.
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Prior OIG work found that improper use of modifiers during
the global surgery period resulted in inappropriate payments.
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The global surgery payment includes a surgical service and
related preoperative and postoperative E/M services
provided during the global surgery period.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
29
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April 3 - St. Luke’s University Health Network has agreed to pay
$1,029,791 to resolve allegations that from January 1, 2002, through
June 30, 2012, it erroneously submitted claims to the Medicare
program for payment that contained evaluation and management
services that were not allowable under Medicare.
◦ Medicare does not normally allow additional payments for such
services performed by a provider on the same day as a procedure,
unless the service is significant, separately identifiable, and above
and beyond the usual preoperative and postoperative care
associated with the procedure.
 In such cases, an attachment to the claim, known as "Modifier
25," may be submitted to allow the additional payment.
◦ In this matter, the government determined that St. Luke’s
incorrectly attached Modifier 25 to Medicare claims that led
Medicare to pay for evaluation and management services that
were not significant and separately identifiable from the
underlying procedures for which Medicare also made payments.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
30
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Eligible professionals may earn an incentive payment for
electronic prescribing for 2013.
◦ Eligible professionals who receive the electronic health
records incentive payment are not entitled to receive
an e-Rx incentive.
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The basics of the e-Rx Incentive Program have not
changed.
31
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Eligible professionals may participate one of two ways
◦ as an individual eligible professional
◦ as part of a group practice participating in the group
practice reporting option (GPRO) for the e-Rx Incentive
Program (e-Rx GPRO)
 Now defined as 25 or more eligible professionals
 Must also participate in PQRS
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For 2013, there are three different reporting mechanisms:
◦ Claims-Based
◦ Registry
◦ Electronic Health Records
32
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Eligible professionals who successfully report the e-Rx
measure are entitled to the following incentives:
◦ 0.5 percent for 2013
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Eligible professionals who do not successfully meet the
reporting requirements during the first 6 months of the
previous year or do not meet one of the exceptions will
have their Medicare fee for service payments reduced
for the following year.
◦ 1.5 percent for 2013
◦ 2.0 percent for 2014
33
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Enrolled in Medicare on or after July 1, 2013
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Successfully reported at least 25 unique e-Rx events
between January 1 and December 31, 2012
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Submit at least 10 unique e-Rx events between January 1
and June 30, 2013
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Request and receive an hardship exemption
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
34
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Report the following e-Rx numerator G-code, when applicable:
◦ G8553 At least one prescription created during the encounter
was generated and transmitted electronically using a qualified
e-Rx system.
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The e-Rx G-code, which supplies the numerator, must be
reported:
◦ on the same claim as the denominator billing code
◦ for the same beneficiary
◦ for the same date of service (DOS)
◦ by the same EP (individual NPI) who performed the covered
service as the payment codes, usually ICD-9-CM, CPT
Category I or HCPCS codes, which supply the denominator
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
35
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If an eligible professional (EP) earns an incentive under
the Medicare EHR Incentive Program, he or she cannot
receive an incentive payment under the e-Rx Incentive
Program in the same program year
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If an EP earns an incentive under the Medicaid EHR
Incentive Program, he or she can receive an incentive
payment under the e-Rx Incentive Program in the same
program year.
36
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The Physician Quality Reporting System is a voluntary
quality reporting program that provides an incentive
payment to practices whose eligible professionals
(identified on claims by their individual National
Provider Identifier [NPI]) satisfactorily report data on
quality measures for covered Medicare Physician Fee
Schedule (PFS) services furnished to Medicare Part B
Fee-For-Service (FFS) beneficiaries
37
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For 2012 through 2014, eligible professionals may earn
an incentive payment of 0.5 percent of their total

Penalties for not successfully reporting PQRS measures
begins in 2015
◦ 1.5% payment adjustment for 2015
◦ 2.0% payment adjustment for 2016 and after
38
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2 Measure options
◦ Individual measures
◦ Measures group
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3 Reporting Options
◦ Claims based
◦ Registry
◦ Electronic Health Record
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2 Reporting Periods
◦ 12 months (January 1, 2013 through December 31, 2013) Claims
must be submitted no later than February 28, 2014
◦ 6 months (July 1, 2013 through December 31, 2013) Must be
submitted no later than February 28, 2014 (Measures Group
registry reporting only)
39
Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in
Diabetes Mellitus
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Description:
◦ Percentage of patients aged 18 through 75 years with diabetes mellitus
who had most recent hemoglobin A1c greater than 9.0%
Reporting Options
◦ Claims-based
◦ Registry-based
Instructions:
◦ This measure is to be reported a minimum of once per reporting period
for patients with diabetes mellitus seen during the reporting period. The
performance period for this measure is 12 months. The most recent
quality-data code submitted will be used for performance calculation.
This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the
measure-specific denominator coding.
40
An ICD-9 diagnosis code for diabetes and a CPT E/M service
code or G-code are required to identify patients for
denominator inclusion.
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ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11,
250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32,
250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53,
250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80,
250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01,
362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.00, 648.01,
648.02, 648.03, 648.04
AND
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CPT E/M service codes or G-codes: 97802, 97803, 97804, 99201,
99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305,
99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328,
99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347,
99348, 99349, 99350, G0270, G0271
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
41
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3046F: Most recent hemoglobin A1c level > 9.0%
OR
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3046F-8P: Hemoglobin A1c level was not performed during
the performance period (12 months)
OR
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3044F: Most recent hemoglobin A1c (HbA1c) level < 7.0%
OR
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3045F: Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0%
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
42
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To avoid the 2015 PQRS payment adjustment, individual
eligible professionals and CMS-selected group practices
participating in the PQRS Group Practice Reporting
Option (GPRO) will have to satisfactorily report data on
quality measures for covered professionals services
provided in 2013.

Reporting during the 2013 PQRS program year will be
used to determine whether a PQRS payment adjustment
applies in 2015.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
43

The Affordable Care Act provides for incentive
payments equal to 10 percent of a primary care
practitioner's allowed charges for primary care services
under Part B, furnished on or after January 1, 2011 and
before January 1, 2016.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
44
Primary care practitioners must meet all the following criteria
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Physicians who have a primary specialty designation of family
medicine, internal medicine, geriatric medicine, or pediatric
medicine; as well as nurse practitioners, clinical nurse specialists,
and physician assistants for whom primary care services accounted
for at least 60 percent of the practitioner’s MPFS allowed charges
◦ New and established patient office or other outpatient visits (CPT
codes 99201 through 99215)
◦ Nursing facility care visits, and domiciliary, rest home, or home
care plan oversight services (CPT codes 99304 through 99340)
◦ Patient home visits (CPT codes 99341 through 99350)
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
45
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No other action required to participate and receive
incentive payments
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Incentive payments are based on the Medicare paid
amounts for the CPT codes designated as primary care
on the previous slide

Incentive payments are made quarterly
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Primary care practitioners also eligible for the 10 percent
Health Professional Shortage Area Bonus are also
eligible for the Primary Care Incentive Payment = 20%
total incentives for primary care services
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
46

Under the Affordable Care Act (ACA), states must raise the
Medicaid fees they pay for primary care services provided by
family physicians, internists, pediatricians, and nurse practitioners
and physician assistants to the level Medicare pays for those
services.

The purpose of this section of the ACA was to increase the
availability of primary care providers in anticipation of increased
demand beginning in 2014 under Medicaid expansion.

On average, in 2012, the fees paid for Medicaid primary care
services were about 58% of those paid by Medicare.

The increase will especially benefit individuals who are eligible for
Medicare and Medicaid since primary care providers now will
receive the full Medicare amount.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
47

Transitional Care Management (TCM)
◦ Covered and paid by Medicare
◦ Other insurers should also reimburse, but will depend
on contract

Complex Chronic Care Coordination Services (CCCC)
◦ Bundled by Medicare
◦ Contact contracted insurers to know if separately
billable
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
48

The transition in care is from:
◦
◦
◦
◦

an inpatient hospital setting (acute care, rehab, LTAC)
partial hospital
observation status in a hospital
skilled nursing facility/nursing facility
To the patient’s community setting:
◦
◦
◦
◦
home
domiciliary
rest home
or assisted living
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
49

TCM is comprised of one face-to-face visit within the
specified time frames, in combination with non-face-to-face
services that may be performed by the physician or other
qualified health care professional and/or licensed clinical
staff under his or her direction.
◦ When provided, report TCM code for the first face-to-face
visit following discharge
◦ These codes are NOT part of the Teaching Physician
Primary Care Exception and require the teaching physician
to evaluate the patient when the face-to-face visit is
provided by a resident
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
50


Per CPT, TCM are for services to an established patient
and whose medical and/or psychosocial problems
require moderate or high complexity medical decision
making during transitions in care.
CMS will allow physicians to bill these codes for new
patients, not just established patients
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
51

The required contact with the patient or caregiver, as
appropriate, may be by the physician or qualified health
care professional or clinical staff.
◦ Within two business days of discharge is Monday
through Friday except holidays without respect to
normal to normal practice hours or date of notification
of discharge
◦ Contact may be
 Direct (face-to-face)
 Telephonic, or by
 Electronic means
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
52

The contact must include capacity for prompt interactive
communication addressing patient status and needs
beyond scheduling follow-up care.
◦ If two or more separate attempts are made in a timely
manner, but are unsuccessful and other transitional
care management criteria are met, the service may be
reported.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
53

99495 Transitional Care Management Services with the
following required elements:
◦ Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business
days of discharge
◦ Medical decision making of at least moderate
complexity during the service period
◦ Face-to-face visit within 14 calendar days of discharge
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
54

99496 Transitional Care Management Services with the
following required elements:
◦ Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business
days of discharge
◦ Medical decision making of at least high complexity
during the service period
◦ Face-to-face visit within 7 calendar days of discharge
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
55
Non-face-to-face services provided by the physician or other qualified
health care provider may include:
 Obtaining and reviewing the discharge information (e.g., discharge
summary, as available, or continuity of care documents);
 Reviewing need for or follow-up on pending diagnostic tests and
treatments
 Interaction with other qualified health care professionals who will
assume or re-assume care of the patient’s system-specific problems
 Education of patient, family, care guardian, and/or caregiver
 Establishment or reestablishment of referrals and arranging for
needy community resources
 Assistance in scheduling any required follow-up with community
providers and services
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
56
Non-face-to-face services provided by clinical staff, under the direction
of the physician or other qualified health care professional, may
include:
 Communication (with patient, family members, guardian or
caretaker, surrogate decision makers, and/or other professionals)
regarding aspects of care;
 Communication with home health agencies and other community
services utilized by the patient;
 Patient and/or family/caretaker education to support selfmanagement, independent living, and activities of daily living;
 Assessment and support for treatment regimen adherence and
medication management;
 Identification of available community and health resources;
 Facilitating access to care and services needed by the patient and/or
family.
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Modifiers Copyright 2012 American
Medical Association
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Only one individual may report these services and
only once per patient within 30 days of discharge.
◦ Another TCM may not be reported by the same individual
or group for any subsequent discharge(s) within the 30
days. Will require good coordination with other physicians
involved in the patient’s hospitalization
The same individual may report hospital or observation
discharge services and TCM.
The same individual should not report TCM services
provided in the postoperative period.
◦ If another individual provides TCM services within the post
operative period of a surgical package, modifier is not
required. (Coding tip, not guideline)
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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CCCC Patients:
◦ Typically have 1 or more chronic continuous or episodic
health conditions
◦ Commonly require the coordination of a number of
specialties and services
◦ May have medical and psychiatric behavioral comorbidities complicating their care
◦ May have social support weaknesses or access to care
difficulties
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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Patients requiring CCCC may be identified by:
◦ Algorithms that utilize reported conditions and
services (e.g., predictive modeling risk score or repeat
admissions or emergency department use)
OR
- Clinical judgment
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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CCCC Services are:
◦ Patient centered management and support services
provided by physicians, other qualified health care
professionals (QHP) and clinical staff
◦ Provided to an individual residing in a home or in a
domiciliary, rest home, or assisted living facility (not
in a skilled nursing facility and not a hospice patient)
◦ A care plan directed by a physician or QHP and
typically implemented by clinical staff
◦ Services that address the coordination of care by
multiple disciplines and community service agencies.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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The reporting individual provides or oversees the
management and/or coordination of services, as
needed, for:
◦ All medical conditions
◦ Psychosocial needs
◦ Activities of daily living
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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99487 Complex chronic care coordination service; first
hour of clinical staff time directed by a physician or
other qualified health care professional with no face-toface visit per calendar month
99488 CCCC first hour of clinical staff time
directed by a physician or other qualified health care
professional with one face-to-face visit, per calendar
month
99489
each additional 30 minutes of clinical staff
time directed by a physician or other qualified health
care professional, per calendar month (List separately in
addition to code for primary procedure)
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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Payment for minor surgical procedures includes
payment for certain E/M services that are necessary
prior to a procedure being performed.
◦ It may be necessary to indicate that on the day a
procedure or service was performed, the patient's
condition required a significant, separately identifiable
E/M service above and beyond the usual preoperative
and postoperative care associated with the procedure
that was performed.
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Modifiers Copyright 2012 American
Medical Association
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Definition
◦ Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the
Same Day of the Procedure or Other Service
When a provider performs an E/M service on the same
day as a procedure that is significant, separately
identifiable, and above and beyond the usual
preoperative and postoperative care associated with the
procedure, modifier -25 should be appended to the visit
code.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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An investigation into the billing patterns of a major
healthcare facility in Ohio revealed modifier -25 was
being appended to outpatient clinic visits when there
was no documentation in the medical records to support
that a significant, separately identifiable E/M service
was performed.
◦ The overpayment dollar amount for this facility was
over $500,000.
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Modifiers Copyright 2012 American
Medical Association
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Modifier -25 is not used to report an E/M service that
resulted in a decision to perform surgery.
◦ The -57 modifier is not used with minor surgeries
because the global period for minor surgeries does not
include the day prior to the surgery.
◦ Moreover, where the decision to perform the minor
procedure is typically done immediately before the
service, it is considered a routine preoperative service
and a visit is not billed in addition to the procedure.
Carriers should not pay for an evaluation and
management service billed with the CPT modifier -57 if
it was provided on the day of or the day before a
procedure with a 0 or 10-day global surgical period.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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A patient comes to the office with complaints of right
knee pain. The physician takes a history and does an
exam. An X-ray of the knee is obtained and the
physician writes an order for physical therapy. He
determines that the patient would benefit from a
cortisone injection to the affected knee.
◦ In this case, a separate and significant E/M service
was prompted by the knee pain for which the
cortisone injection was given.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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An established patient is seen in the office for debridement of
mycotic nails. In the course of examining the feet prior to the
procedure, Tinea Pedis is noted. Use of previously prescribed
topical cream to treat the Tinea is recommended.

In this case the Tinea was noted incidentally in the course of
the evaluation of the mycotic nails and did not constitute a
significant and separately identifiable E/M service above and
beyond the usual pre and post care associated with nail
debridement.
CPT Codes, Descriptions, and
Modifiers Copyright 2012 American
Medical Association
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Modifier 57 AMA Definition
◦ Decision for Surgery: An evaluation and management
service that resulted in the initial decision to perform
the surgery may be identified by adding modifier 57 to
the appropriate level of E/M service.
Modifier -57 CMS Definition
◦ Carriers pay for an evaluation and management
service on the day of or on the day before a procedure
with a 90-day global surgical period if the physician
uses CPT modifier -57 to indicate that the service
resulted in the decision to perform the procedure.
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Modifiers Copyright 2012 American
Medical Association
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CMS also instructs physicians to append the -25
modifier even though these services are not subject to
the global surgical package pricing
◦ Smoking Cessation
◦ E/M with IM/SubQ injection of therapeutic
medication
◦ Problem-oriented E/M on the same day as a Medicare
preventive visit, e.g., IPPE, AWV
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Modifiers Copyright 2012 American
Medical Association
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If you perform a test, be certain that the order is noted
somewhere in the medical record.
Test requisitions must be personally signed by the
provider.
Some tests require a written interpretation and report,
e.g., ECGs, x-rays.
The claim must include the valid NPI of the
ordering/referring physician or extender.
◦ Individual ordering the test in the medical record
must be shown as the ordering provider on the claim
(Box 17 & 17B of CMS 1500) for the diagnostic test
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Modifiers Copyright 2012 American
Medical Association
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Questions?
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