CMS issued Transmittal 11842 which brings about some significant changes to the manual.
CMS is revising the following sections of the Centers for Medicare & Medicaid Services (“CMS”) Claims Processing Manual (Pub. 100-04), Chapter 12:
- Section 30.6.1 Selection of Level of Evaluation and Management Service, (Rev. 11842, Issued: 02-09-23, Effective: 01-01-23, Implementation: 01-01-23); B. Selection of Level of Evaluation and Management Service.
- Section 30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 – 99215) (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23).
- There are three new subsections under 30.6.7:
- E. Prolonged Office/Outpatient E/M Visits
- F. Add-On Code for Office/Outpatient E/M Visit Complexity
- G. Medical Review When Practitioners Use Time to Select Visit Level
- There are three new subsections under 30.6.7:
- Section 30.6.8 – Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23).
- Physician Billing for Observation Care Following Initiation of Observation Services was completely rewritten with new requirements reflecting the changes of the observation care codes.
- Admission to Inpatient Status Following Observation Care subsection D was updated with changes regarding the transition of services from observation status to inpatient status.
- Section 30.6.9 – Payment for Inpatient Hospital Visits – General (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23).
- Two Hospital Visits Same Day was significantly updated expanding on “per day,” “date of encounter,” and “calendar date.”
- Under Subsection E Definition of Initial and Subsequent Visit provides a detailed definition of both terms.
- At subsection F Prolonged Hospital Inpatient or Observation Care Services addresses observation care visits using G0316.
- Section 30.6.9.1 – Payment for Initial Hospital Inpatient or Observation Care Services and Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services) (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23)
- Subsections A and B are slightly expanded with the most significant changes at subsection C Initial Hospital Inpatient or Observation Care and Discharge on Same Day providing a detailed chart related to observation care of 8 hours but less than 24 hours and which codes apply to hospital stays less than 8 hours, hospital stay 8 hours or more, and which calendar day the patient is discharged. These factors determine which CPT® code to bill: initial hospital service only, same-day admission discharge, initial hospital services only, or initial hospital services plus discharge day management code.
- Section 30.6.9.2 – Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management (Codes 99231 – 99239) (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23)
- Section 30.6.13 – Nursing Facility Services (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23) adding the definition of initial and subsequent visits.
- Section 30.6.15 – Prolonged Services, Standby Services, and Evaluation and Management Service for Power Mobility Devices (PMDs) (G0372) (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23)
- NEW Section 30.6.15.2 Prolonged Office/Outpatient E/M Visits (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23)
- NEW Section 30.6.15.3 Prolonged Other E/M Visits (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23)
- This section has a detailed table on how to properly report the prolonged code G0316 and the time threshold to report the code.
- Section 30.6.18 – Split (or Shared) Visits (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23)
