Evaluation and Management

Hospital Inpatient or Observation Evaluation and Management Add-On Code G0545 for Infectious Diseases

Effective 1/1/2025

Definition of G0545

Visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases specialist, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment (add-on code, list separately in addition to hospital inpatient or observation evaluation and management visit, initial, same day discharge, subsequent or discharge).

Billing Information

Payment for G0545 may be billed with inpatient hospital or observation visit codes:

  • CPT Codes
    • 99221–99223 (Initial visit)
    • 99231–99233 (Subsequent visit)
    • 99234–99236 (Same-day admission/discharge visit)
    • 99238–99239 (Discharge visit)
  • G0545 is not intended to be a time-based code.
    • For time-based reporting of additional incremental time, see prolonged hospital I/O E/M codes.
  • G0545 is aimed to be used for the inherent complexity for all infectious diseases and not just emerging infectious diseases with epidemic potential.
  • Utilized by practitioners who have specialized infectious disease training, including but not limited to physicians, nurse practitioners, physician assistants, and certified nurse specialists.

Key Components

G0545 includes the following service elements, you may use one or any combination, of the three service elements below.

  1. Disease Transmission Risk Assessment and Mitigation
    • Developing, following, and supervising specialized, individualized infection control protocols for an individual patient based on their diagnosis and risks in order to reduce risk of disease transmission.
    • Coordinating with human resources regarding infection prevention and control measures to enable healthcare facility staff to safely care for patient.
    • Counseling patients, family members and caregivers regarding infection prevention.
    • Managing infection prevention and treatment protocols associated with transitions of care for complex patients.
  1. Public Health Investigation, Analysis and Testing
    • In-depth patient chart review that entails going back farther in time and assessing the complete breadth of all health care interactions, with higher-level synthesis for complex diagnoses.
    • Communicating with the clinical microbiology lab and directly reviewing specimens.
    • Coordinating specialized diagnostic evaluations (for example, identifying and facilitating diagnostic laboratory tests only available at specialized laboratories, the state health department, and/or the Centers for Disease Control & Prevention).
    • Coordinating with federal, state and local public health agencies and laboratories to assist with contact tracing, obtaining specimens for specialized testing, and/or identifying prior testing and treatment for communicable diseases in other jurisdictions.
  1. Complex Antimicrobial Therapy Counseling and Treatment
    • Counseling patients, family members and caregivers regarding antimicrobial stewardship and resistance for the patient.
    • Engaging in complex medical decision-making associated with antimicrobial prescribing including considerations such as antimicrobial resistance patterns, emergence of new variants/strains, recent antibiotic exposure, interactions/complications from comorbidities including concurrent infections, public health considerations to minimize development of antimicrobial resistance, and emerging and re-emerging infections.

ICD-10-CM Code

  • No specific diagnosis is required for HCPCS code G0545.
  • It would be appropriate to report a health condition that is a confirmed or suspected infectious disease by an infectious disease specialist. 

Cost Sharing

Part B patient coinsurance and deductible will apply.

Documentation

  • There are no specific additional medical record documentation requirements.
    • The medical record or claims history for a patient/practitioner combination, such as diagnoses, the practitioner's assessment and medical plan of care, and/or other codes reported could serve as supporting documentation.

Example

Clostridium difficile (C. difficile) infection poses significant challenges in healthcare settings, particularly in inpatient facilities. It is important to follow detailed coding and documentation guidelines when dealing with such infections to ensure accurate representation of the care provided.

Here are a few points highlighting the complexity and necessary precautions:

  1. Complicating Antibiotic Selection: C. difficile infections often emerge as a complication of antibiotic therapy, necessitating careful selection of antibiotics to treat the primary infection without exacerbating the C. difficile infection.
  2. Infection Control Measures: Preventing the spread of C. difficile in an inpatient setting requires stringent infection control strategies, such as isolation of infected patients, proper hand hygiene, and environmental cleaning.
  3. Coding and Documentation: Accurate coding requires several descriptor elements that must be documented by the treating clinician:
    • The diagnosis of C. difficile infection.
    • Details about the severity and any complications.
    • The treatment plan, including any specific antibiotics or interventions required.
  1. Clinical Responsibility: The treating clinician must ensure all necessary elements are recorded meticulously to not only facilitate accurate billing but also to contribute to patient safety and quality of care.

By adhering to these practices, healthcare providers can manage and document C. difficile infections effectively, optimizing both patient outcomes and compliance with coding requirements.

Resources

Posted 3/18/2025