The new year will bring in new limits for new prolonged service codes

by: Julia Kyles, CPC Dec 4, 2023

When Medicare finalized its new prolonged services codes for E/M visits in the hospital, nursing facility and home or residence settings (G0316-G0318), it also announced that it would not apply frequency limits to the 15-minute add-on codes (PBN 11/10/22 subscription required). But that policy is on its way out. CMS will implement medically unlikely edits (MUE) for the codes on Jan. 1, 2024.

According to the practitioner MUE file, CMS will set an MUE of 4 for each code. The agency cites clinical data as the rationale for the limits. A treating provider will be able to report four units of service, which amounts to 60 minutes of time past the threshold for the primary code.

CMS assigned each code an MUE adjudication indicator of “3” to the edits, so you can appeal MUE-based denials. However, you should remind your coding and care teams that the chart must clearly support the medical necessity of the extra time when you alert them to this update. And you should expect the appeals process to be particularly tough.

CMS sets a high bar for all MUE appeals. The reviewer will check the records “to determine if the provider/supplier actually furnished units in excess of the MUE, if the codes were used correctly, and whether the services were medically reasonable and necessary,” CMS explained in an FAQ on MUEs.

In addition, CMS gives reviewers the final say on time-based coding. “Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit,” CMS wrote in IOM 100-04, chapter 12, §30.6.7(G).

CMS has not shared any details on the factors that go into the objective determination, but it is a safe bet that an appeal will fail if the provider only documents the time and gives minimal details on the work they performed.

Blog Tags: CMS

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