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psychiatric illness with potential threat to self or others, peritonitis, acute renal failure) ● An abrupt change in neurologic status (for example, seizure, TIA, weakness, sensory loss) ● Cardiovascular imaging studies with contrast with identified risk factors ● Cardiac electrophysiological tests ● Diagnostic endoscopies with identified risk factors ● Discography ● Elective major surgery (open, percutaneous or endoscopic) with identified risk factors ● Emergency major surgery (open, percutaneous or endoscopic) ● Parenteral controlled substances ● Drug therapy requiring intensive monitoring for toxicity ● Decision not to resuscitate or to de-escalate care because of poor prognosis Documentation of an Encounter Dominated by Counseling and/or Coordination of Care When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/ or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, you should document the total length of time of the encounter and the record should describe the counseling and/or activities to coordinate care. The Level I and Level II CPT® books, available from the American Medical Association, list average time guidelines for a variety of E/M services. These times include work done before, during, and after the encounter. The specific times expressed in the code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances. Table 5 (cont.): Table of Risk Page 21 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet OTHER CONSIDERATIONS Split/Shared Services A split/shared service is an encounter where a physician and a NPP each personally perform a portion of an E/M visit. Here are the rules for reporting split/shared E/M services between physicians and NPPs: ● In the office or clinic setting: • For encounters with established patients who meet incident to requirements, use either practitioner’s National Provider Identifier (NPI) • For encounters that do not meet incident to requirements, use the NPP’s NPI ● Hospital inpatient, outpatient, and ED setting encounters shared between a physician and a NPP from the same group practice: • When the physician provides any face-to-face portion of the encounter, use either provider’s NPI • When the physician does not provide a face-to-face encounter, use the NPP’s NPI Consultation Services Effective for services furnished on or after January 1, 2010, Medicare no longer recognizes inpatient consultation codes (CPT codes 99251–99255) and office and other outpatient consultation codes (CPT codes 99241–99245) for Part B payment purposes. However, Medicare recognizes telehealth consultation codes (HCPCS G0406–G0408 and G0425–G0427) for payment. Physicians and NPPs who furnish services that, prior to January 1, 2010, would have been reported as CPT consultation codes, should report the appropriate E/M visit code to bill for these services beginning January 1, 2010. KEY TAKEAWAYS ● While E/M services vary in several ways, such as the nature and amount of physician work required, good general documentation principles help ensure that medical record documentation for all E/M services is appropriate. ● When billing for a patient’s visit, select codes that best represent the services furnished during the visit. The provider must also ensure that medical record documentation supports the level of service reported to a payer. You should not use the volume of documentation to determine which specific level of service to bill.
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