February 17, 2023 | By Brenda Edwards, CPC, CDEO, CPB, CPC-I, CEMC, CRC, CMRS, CMCS
Happy Friday! We have our first month of 2023 behind us which means the first of the claims for the new year have been submitted. Here’s the $100,000 question – are you claims paying appropriately with the 2023 Evaluation and Management (E/M) changes that have occurred?
Are your consultations being coded correctly? Remember that the low level, 99241 and 99251, have been deleted. I spoke to somebody just this week who couldn’t understand why the consultations being submitted to Medicare are denying. A gentle reminder that Medicare has not accepted consultations for many years… As a seasoned coder/auditor/biller you may be aware of this but are the newer staff members aware of this?
Now let’s discuss observation codes for 2023. Did your initial claims pay correctly for observation services? I would venture to say if you have billed any Medicare claims between 1/1/23 and 1/23/23 your claims denied for a variety of reasons. The reason the claims denied is the claims processing system had a glitch. The good news is the system was corrected 1/23/23 and Medicare Administrative Contractors (MACs) are performing mass adjustments of the affected claims. This included codes 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239 in places of service 10, 22, 23, and 62. If the MACs had this problem, have you considered how many other payors may have had a similar situation? Denials have to be monitored to ensure incorrect processing isn’t occurring.
Anybody wonder why CMS created three separate codes to report 99418 (inpatient prolonged services)? I think CMS scored big on this one. Their three codes allow more specific reporting for hospital inpatient and observation (G0316), prolonged nursing facility (G0317), and prolonged home or residence (G0318). In fact, these codes allow the provider to report time spent before and after the date of visit!
+G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service.
| Primary E/M | Time Threshold to
Report Prolonged |
Count physician/NPP time spent within this time period (surveyed timeframe) |
| 99223 | 105 minutes | Date of visit |
| 99233 | 80 minutes | Date of visit |
| 99236 | 125 minutes | Date of visit to three days after |
+G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service.
| Primary E/M | Time Threshold to
Report Prolonged |
Count physician/NPP time spent within this time period (surveyed timeframe) |
| 99306 | 95 minutes | 1 day before visit + date of visit +3 days after |
| 99310 | 85 minutes | 1 day before visit + date of visit +3 days after |
+G0318 Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service.
| Primary E/M | Time Threshold to
Report Prolonged |
Count physician/NPP time spent within this time period (surveyed timeframe) |
| 99345 | 141 minutes | 3 days before visit + date of visit + 7 days after |
| 99350 | 112 minutes | 3 days before visit + date of visit + 7 days after |
Have you considered how the time before and after the date of visit will be recorded? If the provider has to lock the note in a set amount of time, how will the after visit time be documented and tracked in electronic systems? What date of service for the 3 days before and 7 days after the visit? Interesting things to contemplate!
Have you run into any other conundrums this year? If you have, that probably means somebody else has as well. Make sure you are networking with your colleagues to catch glitches and share discoveries that will help with the bottom line of every provider, practice and hospital.
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
