Selection of Level of Evaluation and Management Service

30.6.1 - Selection of Level of Evaluation and Management Service (Rev .11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23) A. General Rules Advise physicians to generally use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management (E/M) services. Medicare has created Medicare-specific codes that must be used to report prolonged E/M services and E/M visit complexity add-on services. Medicare will pay for E/M services for specific, non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS), and certified nurse midwife (CNM)), whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service; however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary, and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. B. Selection of Level of Evaluation and Management Service As of January 1, 2023, for most E/M visit families, practitioners will select visit level based on the level of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner. For some types of visits (such as emergency department visits and critical care), in accordance with their CPT codes, practitioners do not have this choice and will use only MDM or only time to bill. The CPT E/M Guidelines for MDM apply. For all E/M visits, history and physical exam must be performed in accordance with code descriptors, but history and exam no longer impact visit level selection. When practitioner time is used to select visit level, the full time must be completed; the general CPT rule regarding the midpoint for certain timed services does not apply. Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. Any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid by the Medicare Administrative Contractor (MAC) at the appropriate physician fee schedule amount based on the rendering national provider identifier (NPI) number. "Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met (refer to sections 60.1, 60.2, and 60.3, chapter 15 in IOM 100-02). SPLIT/SHARED E/M SERVICE See section 30.6.18 for rules regarding billing of E/M visits that are split (or shared).