E&M Services Not Separately Reimbursable

E&M Services Not Separately Reimbursable: The following CPT-4 codes for E&M services are not separately reimbursable if billed by the same provider, for the same recipient Reimbursable and same date of service. In such cases, for the following code combinations, reimbursement will be made only for the higher paying of the codes billed.

New patient, office or other outpatient visit (99201 – 99205) and another new patient, office or other outpatient visit (99201 – 99205)

Prolonged E&M Services – Prolonged services include outpatient services (CPT-4 codes 99354 and 99355) and inpatient services (CPT-4 codes 99356 and 99357). Reimbursement for these codes requires a minimum of 30 minutes face-to-face contact or unit/floor time beyond the typical time of the visit to be reported. A prolonged service of less than 30 minutes is included in the original visit and should not be reported.

Outpatient Services CPT 99354 – To report prolonged outpatient E&M services, CPT-4 codes 99354 (office or outpatient setting; first hour) must be billed in conjunction with one of the following E&M codes.

CPT-4 Code Description

Office or other outpatient visit

99201 – 99205

99212 – 99215

Office or other outpatient consultation

99241 – 99245

Domiciliary, rest home, or custodial care visit

99324 – 99328

99334 – 99337

Home Visit

99341 – 99345

99347 – 99350

Outpatient psychotherapy with E&M component

90809, 90815