The Physicians’ Current Procedural Terminology – 4th Edition (CPT-4) book includes codes for billing Evaluation and Management (E&M) procedures. It is important that providers use the current version of the CPT-4 and report E&M code definitions carefully.
General Information: The following paragraphs include general information about E&M procedures.
Levels of Care : Within each category and subcategory of E&M service, there are three to five levels of care available for billing purposes. These levels of care are not interchangeable among the different categories and subcategories of service. The components used to describe and define the various levels of care are listed in the “Evaluation and Management” section of the CPT-4 book.
Modifiers: Modifiers used to describe circumstances that modify a listed E&M code are listed with their descriptors in the Modifiers: Approved List and Modifiers Used With Procedure Codes sections of the appropriate Part 2 manual.
New Patient : A new patient is one who has not received any professional services. Reimbursement from the provider within the past three years. If a new patient visit has been paid, any subsequent claim for a new patient service by the same provider, for the same recipient received within three years will be paid at the level of the comparable established patient procedure.
RAD Reductions : The payment resulting from this change in the level of care will be made with a Remittance Advice Details (RAD) message defining the reduction as being in accordance with the service limit set for the procedure. These codes are listed in the Remittance Advice Details (RAD) Codes and Messages: 001 – 9999 sections in the Part 1 manual. Providers who consider the service appropriate and the reduction inappropriate should submit a Claims Inquiry Form (CIF).
Established Patient Reimbursement : An established patient is one who has received professional services from the provider within the past three years.
E&M Services Separately Reimbursable : The following CPT-4 codes for E&M services are separately reimbursable if billed by the same provider, for the same recipient and same date of service, and if the required documentation is included in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim or on an attachment included with the claim.
New patient, office or other outpatient visit (99201 – 99205) and established patient, office or other outpatient visit (99211 – 99215)
Claims for codes 99211 – 99215 must document the following: The patient was seen on two separate occasions on the same date of service (the patient left the provider’s office and returned for a second visit); and Medical necessity.
New patient, office or other outpatient visit (99201 – 99205) and new or established patient, office or other outpatient consultation (99241 – 99245). Claims for codes 99241 – 99245 must document the following: Another provider requested the patient consultation; Consultation was regarding a separate problem than that of the earlier initial patient visit; and Medical necessity.
Established patient, office or other outpatient visit (99211 – 99215) and another established patient, office or other outpatient visit (99211 – 99215) may be reimbursed when:
The patient was seen on two separate occasions on the same date of service (the patient left the provider’s office and returned for a second visit). Documentation must be submitted with the claim to medically justify two services on the same day.
The same doctor, or two doctors with the same group number, sees the recipient twice on the same day. Documentation must be submitted with the claim to medically justify a second visit on the same date of service by the same or a different doctor.
New or established patient, subsequent hospital care (99231 – 99233) and subacute subsequent care (HCPCS codes X9928 – X9932)
Restricted to any combination of two services by the same provider, for the same recipient and same date of service. Providers may be reimbursed for more than two services if there is documentation that either the patient’s status deteriorated or there was a significant change which necessitated more than two physician visits to the bedside on the same day.
New or established patient, subsequent hospital care (99231 – 99233) and new or established patient, initial inpatient consultation (99251 – 99255)
Code combinations 99231 – 99233 and 99251 – 99255 may be reimbursed when: Two different physicians provide inpatient services to the same recipient on the same date with the same group provider number. Documentation must be submitted with the claim to medically justify two services on the same day.
One physician provides inpatient services to a recipient twice on the same date of service. Documentation must be submitted with the claim to medically justify two services on the same day.
New or established patient, initial hospital care (99221 – 99223) and new or established patient, subsequent hospital care (99231 – 99233) Code combination 99221 – 99223 and 99231 – 99233 may be reimbursed when: Two different physicians provide inpatient services to the same recipient on the same date with the same group provider number. Documentation must be submitted with the claim to medically justify two services on the same day.
One physician provides inpatient services to a recipient twice on the same date of service. Documentation must be submitted with the claim to medically justify two services on the same day.