Catch up on our blog series: Part 1 awaits your reading!
Evaluation and management (E/M) services play a crucial role in the practice of internists, and accurate coding for these visits is essential for the financial well-being of medical practice. However, determining the appropriate level of billing for an E/M code can be challenging for many physicians. As there are several factors impacting coding guidelines for evaluation and management services in internal medicine, we divided these guidelines into two parts. In the first part of this article, we discussed various factors affecting E/M code selection i.e., history, examination, and medical decision-making. In the second part of this article, we will review alternative billing methods such as billing based on time, incident-to-billing for staff services, and billing for consultations.
Coding Guidelines for Evaluation and Management Services in Internal Medicine
1. Billing Based on Time
Billing based on time is an alternative method for selecting a code level. To use this method, the physician must spend at least 50% of the total visit time on counseling or coordinating care for the patient. The typical times outlined in the Current Procedural Terminology (CPT) books are used to determine the corresponding code level. When billing is based on time, documentation of history, examination, and medical decision-making is irrelevant to code selection. However, physicians should still document for the purpose of patient care. Additionally, the total time spent with the patient and the time spent on counseling or coordination of care should be clearly indicated in the medical record.
2. Billing for Services Provided by Staff
Physicians can bill for services performed by their staff if those services are under the physician’s direction. State laws and local regulations may impose limitations on the tasks clinical staff members can perform. Minor visits, such as blood pressure checks or weight checks, can be conducted by a nurse or medical assistant without the patient seeing the physician. In such cases, the established office visit code 99211 may be billed as long as there is an element of evaluation and management, such as counseling or discussion of medication. If the physician personally sees the patient, a 99211 should never be billed. Billing for staff services by a physician is referred to as “incident-to” billing in Medicare regulations, indicating that the services provided are part of the overall service rendered by the physician. This billing approach may also apply to mid-level practitioners like physician assistants or nurse practitioners, as long as they address existing problems under the physician’s direction and immediate availability for assistance.
3. Billing for a Procedure and an Office Visit on the Same Day
There are instances when a physician performs both an E/M visit and a procedure for a patient on the same day. If an office visit code is charged alongside a procedure code, the office visit code is likely to be denied since CPT considers evaluation and management as a bundled component of a procedure. However, if the E/M visit and procedure are unrelated, the physician can be paid for both services by using a modifier. For example, if a patient comes in with a sore throat and also has a wart removed on the same day, the appropriate modifier to use is -25. A modifier is appended to a CPT code on billing paperwork to indicate differentiation from the standard service.
4. Consultation
Physicians generally receive higher reimbursement for consultations compared to comparable office or inpatient visits. However, for an encounter to qualify as a consultation, it must meet certain criteria. First, the encounter must be requested by another physician or qualified healthcare provider. Second, the requesting physician must seek advice on the treatment of the patient, not merely transfer the patient’s care to the consultant. Lastly, the consultant must provide some form of written report to the requesting physician, which can be in the form of a letter or a copy of the progress note. It is essential to note that consultation rules are subject to change, with CMS aiming to reduce the number of consultations by implementing stricter requirements. Both primary care physicians and specialists can bill for consultations.
To summarize, with these coding guidelines for evaluation and management services in internal medicine, internists can ensure accurate billing, appropriate reimbursement, and compliance with regulatory requirements. Accurate coding for evaluation and management services in internal medicine is crucial for both patient care and the financial health of a practice.
Medisys Data Solutions (MDS)
Medisys Data Solutions (MDS) is a trusted medical billing company specializing in providing efficient internal medicine billing services. With our expertise and knowledge of the intricacies of medical coding and billing, MDS ensures accurate and timely reimbursement for internal medicine practices. Our team of skilled professionals understands the unique challenges faced by internists in documenting and coding evaluation and management services. By leveraging our expertise in medical billing, MDS can help internists optimize revenue, improve practice efficiency, and maintain compliance with coding guidelines and regulations.
To gain a comprehensive understanding of internal medicine billing services, we encourage you to get in touch with us. You can reach us via email at info@medisysdata.com or by calling our dedicated phone line at 888-720-8884. Feel free to contact us, and our knowledgeable team will be more than happy to assist you.
