72 hour rule
Clarification of Evaluation and Management (E/M) Payment Policy
MLN Matters® Number: MM7405
Related Change Request (CR) #: 7405
Related CR Release Date: August 26, 2011
Effective Date: January 1, 2011
Related CR Transmittal #: R147BP and R2282CP
Implementation Date: November 28, 2011
Provider Types Affected
Physicians, non-physician practitioners (NPP), and hospices billing Fiscal Intermediaries (FI), Regional Home
Health Intermediaries (RHHI), carriers, and A/B Medicare Administrative Contractors (A/B MAC) for certain
services to Medicare beneficiaries are affected by this article.
What You Need to Know
This article, based on Change Request (CR) 7405, alerts physicians, NPPs and hospices that the Centers for
Medicare & Medicaid Services (CMS) recognized the newly created Current Procedural Terminology (CPT)
subsequent observation care codes (99224-99226). The article also clarifies the use of Evaluation and Management
(E/M) Codes by providers for services in various settings.
Medicare contractors will not search their files to adjust claims already processed, but will adjust claims brought to
their attention. Be sure your billing staffs are aware of these changes.
Background
In the Calendar Year (CY) 2010 Physician Fee Schedule (PFS) final rule with comment period (CMS-1413-FC),
CMS eliminated the payment of all CPT consultation codes (inpatient and office/outpatient codes) for various places
of service except for telehealth consultation Healthcare Common Procedure Coding System (HCPCS) G-codes.
In the CY 2011 PFS final rule with comment period (CMS-1503-FC), CMS recognized the newly created CPT
subsequent observation care codes (99224-99226).
All references to billing CPT consultation codes in the “Medicare Benefit Policy Manual”, Chapter 15, and the
“Medicare Claims Processing Manual”,12, are revised, as a result of CR7405, to reflect the current policy on
reporting E/M services that would otherwise be described by CPT consultation codes.
References to billing observation care codes in the “Medicare Claims Processing Manual”, Chapter 12, section 30.6,
are also revised to account for the new subsequent observation care codes (99224-99226).
Key Points of CR 7405
Consultation Codes No Longer Recognized
Effective January 1, 2010, CPT consultation codes were no longer recognized for Medicare Part B payment. A
previous article, MM6740, Revisions to Consultation Services Payment Policy, issued on December 14, 2009,
informed you that you must code patient evaluation and management visits with E/M codes that represent where the
visit occurred and that identify the complexity of the visit performed. (MM6740, Revisions to Consultation Services
Payment Policy, is available at http://www.cms.gov/MLNMattersArticles/downloads/MM6740.pdf on the CMS
website.)
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CMS instructed physicians (and qualified NPPs where permitted) billing under the Physician Fee Service
(PFS) to use other applicable E/M codes to report the services that could be described by CPT consultation
codes.
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CMS also provided that, in the inpatient hospital setting, physicians (and qualified NPPs where permitted)
who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).
Reporting Initial Hospital Care Codes
CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously
could have been reported with CPT consultation codes, for which the minimum key component work
and/or medical necessity requirements for CPT codes 99221 through 99223 are not documented.
o
Physicians may bill initial hospital care service codes (99221-99223), for services that were
reported with CPT consultation codes (99241 – 99255) prior to January 1, 2010, when the
furnished service and documentation meet the minimum key component work and/or medical
necessity requirements.
Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or
comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which
are greater than the requirements for consultation codes 99251 and 99252. . In situations where the
minimum key component work and/or medical necessity requirements for initial hospital care services are
not met, subsequent hospital care CPT codes (99231 and 99232) could potentially be reported for an E/M
service that could be described by CPT consultation code 99251 or 99252.
o
Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused
interval history” and “an expanded problem focused interval history.” An E/M service that could
be described by CPT consultation code 99251 or 99252 could potentially meet the component
work and medical necessity requirements to report 99231 or 99232.
Physicians may report a subsequent hospital care CPT code for services that were reported as CPT
consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record
appropriately demonstrates that the work and medical necessity requirements are met for reporting
a subsequent hospital care code (under the level selected), even though the reported code is for the
provider's first E/M service to the inpatient during the hospital stay.
o
Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to
cases where there is no other specific E/M code payable by Medicare that describes that service.
Reporting CPT code 99499 requires submission of medical records and contractor manual medical
review of the service prior to payment. Contractors shall expect reporting under these
circumstances to be unusual.
Medicare contractors have been advised to expect changes to physician billing practices
accordingly. Contractors will not find fault with providers who report subsequent hospital care
codes (99231 and 99232) in cases where the medical record appropriately demonstrates that the
work and medical necessity requirements are met for reporting a subsequent hospital care code
(under the level selected), even though the reported code is for the provider's first E/M service to
the inpatient during the hospital stay.
Billing Visits Provided in Skilled Nursing Facilities and Nursing Facilities
The general policy of billing the most appropriate visit code, following the elimination of payments for
consultation codes, will also apply to billing initial visits provided in skilled nursing facilities (SNFs) and
nursing facilities (NFs) by physicians and NPPs who are not providing the federally mandated initial visit.
If a physician or NPP is furnishing that practitioner’s first E/M service for a Medicare beneficiary in a SNF
or NF during the patient’s facility stay, even if that service is provided prior to the federally mandated visit,
the practitioner may bill the most appropriate E/M code that reflects the services the practitioner furnished,
whether that code be an initial nursing facility care code (CPT codes 99304-99306) or a subsequent nursing
facility care code (CPT codes 99307-99310), when documentation and medical necessity do not meet the
requirements for billing an initial nursing facility care code.
CPT Subsequent Observation Care Codes
In CY 2011 PFS final rule with comment period (CMS-1503-FC), CMS recognized the newly created CPT
subsequent observation care codes (99224-99226).
o
o
o
o
For the new subsequent observation care codes, the current policy for initial observation care also
applies to subsequent observation care.
Payment for a subsequent observation care code is for all the care rendered by the treating
physician on the day(s) other than the initial or discharge date.
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.
In the rare circumstance when a patient receives observation services for more than 2 calendar
dates, the physician will bill observation services furnished on day(s) other than the initial or
discharge date using subsequent observation care codes.
How to use modifiers to indicate the status of an ABN
If a provider or supplier expects that the service or item furnished to the beneficiary may be considered
unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used
to inform the beneficiary of his or her financial liability, appeal rights, and protections under the fee-for-service
(FFS) Medicare program.
Providers and suppliers should use the appropriate modifier when submitting such claims to indicate whether
they have or do not have an ABN signed by the beneficiary.
Modifier criteria:
• Modifier GZ -- must be used when physicians, practitioners, or suppliers want to indicate that they expect that
Medicare will deny an item or service as not reasonable and necessary, and they do not have an ABN signed
by the beneficiary.
Note: Effective July 1, 2011, all claims line(s) items submitted with a GZ modifier shall be denied automatically
and will not be subject to complex medical review. For additional information, please refer to the MLN Matters
article MM7228
.
• Modifier GA -- must be used when physicians, practitioners, or suppliers want to indicate that they expect
that Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the
beneficiary on file.
Note: All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed
service with modifier GA or modifier GZ.
For more information concerning ABNs and other types of notices, please refer to the Centers for Medicare &
Medicaid Services’ (CMS) Beneficiary Notices Initiative
page.
Question and Answers on ABN’s
When may an Advanced Beneficiary Notice (ABN) be needed and issued to a beneficiary
who is not in a state of emergency?
An Advanced Beneficiary Notice (ABN) may not be used when a beneficiary is under great
duress. A beneficiary is considered to be under great duress when his or her medical condition
requires.. emergency care. An ABN may be needed and may be used when the beneficiary is not in the state of
great duress. These situations include, but are not necessarily limited to, the following:
a. A transport by air ambulance when the transporting entity has a reason to believe that Medicare is likely to deny
payment on the basis that the transport could be done safely and effectively by ground ambulance transportation.
b. A level of care upgrade, e.g., from Advance Life Support (ALS)-2 to ALS-1, or from ALS to Basic Life Support,
when the transport at the lower level of care is a covered transport.
In which situations is an Advanced Beneficiary Notice (ABN) applicable
when transporting a Medicare beneficiary?
Published 04/21/2003 02:09 PM |
Updated 04/06/2011 05:04 PM |
Answer ID 1893
In which situations is an Advanced Beneficiary Notice (ABN) applicable when transporting a Medicare beneficiary?
The following summarizes situations when an Advanced Beneficiary Notice (ABN) is applicable regarding ambulance
services:
Situation A: Other means of transportation not contraindicated
Statutory Provision: 1861(s)(7) - Benefit Category
ABN Applicable: No
Limitation on Liability Applicable: No
Responsible for Payment: Beneficiary
Situation C: ALS to BLS Downcoding
Statutory Provision: 1862(a)(1)(A) Reasonable & Necessary
ABN Applicable: Yes**
Limitation on Liability Applicable: Yes
Responsible for Payment: Supplier/Provider or Beneficiary if ABN is signed
Situation D: Mileage Partial Denial
Statutory Provision: 1861(s)(7) - Benefit Category
ABN Applicable: No
Limitation on Liability Applicable: No
Responsible for Payment: Beneficiary
**Indicates that an ABN is applicable. However, if it is an emergency transport, ABNs cannot be used, since
beneficiaries are considered under great duress in such situations.
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May an Advanced Beneficiary Notice (ABN) be utilized to
bill the beneficiary for services denied due to an MUE?
Published 04/15/2009 09:54 AM |
Updated 08/09/2011 01:16 PM |
Answer ID 9697
May an Advanced Beneficiary Notice (ABN) be utilized to bill the beneficiary for services
denied due to an MUE?
No, a provider/supplier may not issue an ABN for units of service in excess of an MUE.
Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability
and bill the beneficiary for the denied services. It is a provider/supplier liability.
III. USING AN ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)
IN AN ELECTRONIC FORMAT
There is currently no Centers for Medicare & Medicare Services (CMS) written
policy on electronic issuance of ABNs; however, it is not prohibited. These are
the CMS recommendations offered to provider/suppliers at this time:
*
If an electronic issuance system is used, the beneficiary must be given
the option of requesting paper issuance over electronic if that is what s/he
prefers.
*
ABNs can be printed for issuance, the paper copy signed by the
beneficiary, then scanned for electronic health record (EHR) retention, and the
original paper copy can be given to the beneficiary.
Double Pricing of Revenue Lines for Rural Health Clinic Claims (Bill
Type 71X)
Description of the problem
Rural health clinic claims (type of bill [TOB] 71X) with more than one preventive
services revenue lines (revenue rode 052X) are double pricing.
What this means to you
The Centers of Medicare & Medicaid Services (CMS) has instructed contractors to hold
all rural health clinic claims (TOB 71X) containing preventive services revenue code
052X until further notice.
Current Status:
10/04/2011: This issue is currently in research status. Providers are encouraged to read
the E-mail Updates and to check for the status of this issue on the Production Alerts
section of the National Government Services Web site.
New DDE screens for eligibility requests
The information listed below will now display in ELGA and HIQA. If you perform an eligibility request via ELGA,
the new direct data entry (DDE) screen will display on page 11. However, if you perform an eligibility request
via HIQA, the new DDE screen will display on page 12,
Effective for claims with dates of service on or after January 1, 2011, that are processed on or after October 3,
2011, CWF shall allow a frequency of one every 3 days for the following codes when billed with the GT or GQ
modifier:
• 99231 - Subsequent hospital care
• 99232 - Subsequent hospital care
• 99233 - Subsequent hospital care
Effective for claims with dates of service on or after January 1, 2011, that are processed on or after October 3,
2011, CWF shall allow a frequency of one every 30 days for the following codes when billed with the GT or GQ
modifier:
• 99307 - Subsequent nursing facility care
• 99308 - Subsequent nursing facility care
• 99309 - Subsequent nursing facility care
• 99310 - Subsequent nursing facility care
Part A Hospital Ancillary Services
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Prepay Review of Acute Inpatient Hospital
Services
Medical Review will be initiating prepay probe reviews on Acute Inpatient Hospital services (bill
type 11X), particularly one-day stays. The focus of the review is to determine if the inpatient
admission is necessary or if the care could have been provided more efficiently on an
outpatient basis (e.g., outpatient observation). The major denial in prior reviews for this
service was that an inpatient level of care was not medically necessary. The determination was
the patient could have been managed at a lower level of care, such as observation, and the
records did not support the need for inpatient admission.
According to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM),
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2:
(248
KB)
“Inpatient care rather than outpatient care is required only if the beneficiary's medical
condition, safety, or health would be significantly and directly threatened if care was provided
in a less intensive setting. Without accompanying medical conditions, factors that would only
cause the beneficiary inconvenience in terms of time and money needed to care for the
beneficiary at home or for travel to a physician's office, or that may cause the beneficiary to
worry, do not justify a continued hospital stay”.
This same section also states,
“Review of the medical record must indicate that inpatient hospital care was medically
necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at
any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe
enough to warrant the need for medical care and must receive services of such intensity that
they can be furnished safely and effectively only on an inpatient basis.”
These reviews will be done for claims submitted from the following states: IN, IL, WI, and MI.
Information regarding these reviews is found in the CMS IOM Publication 100-08, Medicare
Benefit Policy Manual, Chapter 6, Section 6.5.
(248 KB)
FFS Revised ABN
The revised Advanced Beneficiary Notice of Noncoverage (ABN), Form CMSR-131, is issued by providers (including independent laboratories),
physicians, practitioners, and suppliers in situations where Medicare
payment is expected to be denied. The revised ABN replaces the ABN-G
(Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS20007). See the revised ABN manual instructions below for detailed
instructions on mandatory and voluntary use of the revised ABN.
Note: Skilled nursing facilities (SNFs) must use the revised ABN for
items/services expected to be denied under Medicare Part B only.
September 20, 2011: Extension of mandatory use date for REVISED
ABN, FORM CMS-R-131, posted for download on May 16, 2011.
Mandatory use date: January 1, 2012
The latest version of the ABN (with the release date of 3/2011 printed in
the lower left hand corner) is now available for immediate use and can be
accessed via the link below. In order for providers and suppliers to have
time to transition to using the newly posted notice, mandatory use of this
version begins on January, 1 2012. All ABNs with the release date of
3/2008 that are issued on or after January 1, 2012 will be considered
invalid.
The mandatory use date has been changed from September of 2011 to January of 2012 to accommodate
those providers and suppliers with pre-printed stockpiles of ABNs so that they have additional time to
exhaust their supplies of the outgoing ABN.
The newest version of the ABN and the instructions for use can be
downloaded by clicking on the first link under "Downloads" below.
Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)
MLN Matters® Number: SE1128
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
All Medicare physicians, providers and suppliers who submit claims to Medicare for services and supplies provided
to Qualified Medicare Beneficiaries (QMBs) are affected. This includes providers of services to enrollees of
Medicare Advantage plans.
What You Need to Know: Impact to You
This Special Edition MLN Matters® Article provides guidance from the Centers for Medicare & Medicaid Services
(CMS) to Medicare providers serving QMBs. All Medicare providers are reminded that they may not bill QMBs for
Medicare cost-sharing.
What You Need to Know
All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs must be aware that they
may not bill QMBs for Medicare cost-sharing. This includes deductible, coinsurance, and copayments, known as
“balance billing.” Section 1902(n)(3)(B) 4714 of the Social Security Act prohibits Medicare providers from balance
billing QMBs for Medicare cost-sharing. QMBs have no legal obligation to make further payment to a provider or
Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for
Medicare cost-sharing are subject to sanctions.
What You Need to Do
Refer to the Background and Additional Information Sections of this article for further details and resources about
this guidance. Please ensure that you and your staffs are aware of the current balance billing law and policies
regarding QMBs. Visit the State Medicaid Agency websites of the states in which you practice to learn how to
submit claims if you are not currently submitting claims to a state.
Background
This article provides CMS guidance to Medicare providers to help them avoid inappropriately billing QMBs for
Medicare cost-sharing, including deductible, coinsurance, and copayments. This is known as “balance billing.”
Balance Billing of QMBs Is Prohibited by Federal Law
Under current law, Medicare providers cannot balance bill a QMB. Section 1902(n)(3)(B) 4714 of the Social
Security Act prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing. (Please note, this
section of the Act is available at http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.)
Specifically, the statute provides that the Medicare payment and any Medicaid payment are considered payment in
full to the provider for services rendered to a QMB.
QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or
Part B cost sharing. Providers who balance bill QMB patients may be subject to sanctions based on Medicare
provider requirements established in Sections 1902(n)(3)(C) and 1905(p)(3) of the Social Security Act. Medicare
providers who violate these billing restrictions are violating their Medicare provider agreement.
Please note that the statute referenced above supersedes Section 3490.14 of the “State Medicaid Manual,” which is
no longer in effect, and therefore, may be causing confusion about QMB billing.
QMBs and Benefits
QMBs are persons who are entitled to Medicare Part A and are eligible for Medicare Part B; have incomes below
100 percent of the Federal Poverty Level; and have been determined to be eligible for QMB status by their State
Medicaid Agency.
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Medicaid pays the Medicare Part A and B premiums, deductibles, co-insurance and co-payments for
QMBs.
At the State’s discretion, Medicaid may also pay Part C Medicare Advantage premiums for joining a
Medicare Advantage plan that covers Medicare Part A and B benefits and Mandatory Supplemental
Benefits.
Regardless of whether the State Medicaid Agency opts to pay the Part C premium, the QMB is not liable
for any co-insurance or deductibles for Part C benefits.
Ways to Improve the Claims Process
Effective communications between you and State Medicaid Agencies can improve the claims process for all parties
involved. Therefore, CMS suggests that you take the following four actions to improve communications with State
Medicaid Agencies and better understand the billing process for services provided to QMB beneficiaries:
1. Determine if the State in which you operate has electronic crossover processes with the Medicare
Coordination of Benefits Contractor (COBC) in place or if direct submission to the State Medicaid Agency
is required or available. Nearly all States participate in the Medicare crossover process. It may just be that
particular QMBs need to be added to the eligibility exchange between given States and Medicare. If a
claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the
Medicare remittance advice.
2. Recognize that you must meet any state-imposed requirements and may need to complete the provider
registration process to be entered into the State payment system.
3. Understand the specific requirements for provider registration for the State(s) in which you work.
4. Contact the State Medicaid Agency directly to determine the process you need to follow to begin
submitting claims and receiving payment.
OMB Eligibility and Benefits
Dual Eligibility
Qualified Medicare
Beneficiary (QMB
Eligibility Criteria
Benefits
Income cannot exceed 100% of the
Federal Poverty Level (FPL)
Entitled to Medicare Part
A
Resources cannot exceed $6,600 for a
single individual or $9,910 for an
individual living with a spouse and no
other dependents
Eligible for Medicaid
payment of Medicare
Part B premiums,
deductibles, co-insurance
and co-pays (except for
Part D)
Meets all of the standards for QMB
eligibility as described above, but also
meets the financial criteria for full
Medicaid coverage
Entitle to all benefits
available to QMB, as well
as all benefits available
under the State Plan to a
fully eligible Medicaid
only)
QMB Plus
recipient
Individuals often qualify for full
Medicaid benefits by meeting the
Medically Needy standards, or through
spending down excess income to the
Medically Needy level.
QMB Plus
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Meets all of the standards for QMB eligibility as described above, but also meets the financial criteria for
full Medicaid coverage
Individuals often qualify for full Medicaid benefits by meeting the Medically Needy standards, or through
spending down excess income to the Medically Needy level
Entitle to all benefits available to QMB, as well as all benefits available under the State Plan to a fully
eligible Medicaid recipient
For more information about dual eligible categories and benefits, please visit
http://www.medicare.gov/Publications/Pubs/pdf/10126.pdf on the Internet.