Major Changes to the Medicare Claims Processing Manual, Ch. 12

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
• 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)