Evaluation and Management

General E/M Information

Please explain the terms “auxiliary personnel” and “clinical staff” in the context of Medicare services.

Answer: These terms are often used in defining which staff members can perform Medicare services on an “incident to” basis or under varying degrees of physician and/or NPP supervision. National Government Services accepts the following as definitions of these roles:

• Auxiliary personnel (defined in the Code of Federal Register, 42 CFR 410.26) means any individual who is acting under the supervision of a physician (or other practitioner), regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner), has not been excluded from the Medicare, Medicaid and all other federally funded health care programs by the Office of Inspector General or had his or her Medicare enrollment revoked, and meets any applicable requirements to provide incident to services, including licensure, imposed by the State in which the services are being furnished. The term auxiliary personnel encompasses both licensed and unlicensed individuals who are performing incident to a physician in roles that may or may not require licensure.

• The term clinician (as defined by CMS in the Quality Initiatives Patient Assessment Instruments/ Measures System Overview) refers to a healthcare professional qualified in the clinical practice of medicine. Clinicians are those who provide principal care for a patient where there is no planned endpoint of the relationship; expertise needed for the ongoing management of a chronic disease or condition; care during a defined period and circumstance, such as hospitalization; or care as ordered by another clinician. Clinicians may be physicians, nurses, pharmacists, or other allied health professionals. The term clinician refers to a licensed healthcare professional who may be working independently or under the supervision of a physician or NPP.
Is it permissible for a provider (physician or NPP) who has served as an assistant surgeon, or another provider in the surgeon's group, to bill for preoperative or postoperative care relative to the surgery?

Answer: The global surgery fee is paid to the primary surgeon and includes compensation for all standard elements of the surgery (pre, intra and postoperative care). This care is not separately billable or payable by the assistant surgeon or by any member of the primary surgeon’s group, unless the surgeon has transferred a specific segment of that care to another provider.
As per CMS, providers may now reference information obtained and documented at a previous encounter, and information documented by other clinicians, as long as the provider clearly documents current performance of all pertinent E/M elements and updates and/or modifies the record of the previous encounter. Please specify any further recommendation(s) relative to this change.

Answer: The electronic medical record is generally capable of storing an extensive volume of prior documentation. CMS and NGS are concerned with “copy and paste” capability for these records, allowing providers to copy previous information without careful review. Providers are strongly encouraged to avoid any “copy and paste” function when documenting a service. When referencing previously recorded information, the provider should include the date and provider of the prior service, a review of that information relative to the current service and also enter any update or /modification to the prior information.
What is the correct coding for outpatient and/or office services provided during an inpatient stay? For example, during a SNF stay, patients are occasionally seen at a provider’s office. What is the correct coding for these services?

Answer: Outpatient and office services performed during an inpatient stay must be coded by the performing provider with a POS and CPT code that correlates to the facility at which the patient is enrolled in inpatient status. For patients seen during a covered SNF stay, claims should be submitted with POS 31. For patients seen during a noncovered SNF stay, claims should be submitted with POS 32. The office-based physician should choose the correct E/M CPT code from the SNF family of E/M services. CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 80.4 states,

“For example, if SNF inpatients are taken to the private office of a neurologist for necessary tests such as an encephalograph, the services are considered performed in the SNF for billing and payment.”
When is it appropriate to bill CPT code 99211? Can this be used for medication renewals? Does it require the physician or an APRN to be present? Does the patient need to be present (i.e., that service cannot be provided via phone)? Are there time duration limitations?

Answer: CPT code 99211 represents a patient service that does not require the physician’s direct interaction but, must meet the incident to requirements for physician’s presence in the office suite. For example, this code may be appropriate for medication renewals if there is documented interaction by clinical staff with the patient regarding the medication but, does not represent the patient coming into the office to pick up a new prescription at the reception desk. The patient has to be present in the office and telephone services are excluded. As of 1/1/2021, the time component has been removed from this code.
Is it permissible to bill an E/M service performed by a clinical pharmacist?

Answer: Clinical pharmacists are not recognized as enrolled Medicare providers. When working within a physician group practice, the only code that is billable for a service performed by a clinical pharmacist is CPT 99211, and only when that service is performed in full compliance with all CMS incident to guidelines.

Revised 10/22/2024