Billing Guidelines for Dialysis center

Dialysis Centers

Outlined below are generally accepted billing guidelines. This is intended to be illustrative and is not an all-inclusive list.

• Indicate “72X” type of bill. The third digit is based on the type of claim (interim, corrected, etc.).

• Hospital inpatient dialysis departments should bill with their hospital provider number and will be paid under the hospital agreement.

• Bill one claim per calendar month except when training is provided or when hemodialysis is performed in the same month as peritoneal dialysis.

• Do not submit claims that cross over from one month to the other. For example, service dates in January should be on one claim and service dates in February should be on another claim.

• Bill a line item date of service for each revenue code billed on the claim form.

• Revenue codes should be listed in ascending numeric order by date of service and line item billed.

• Bill a separate line item for each dialysis session performed.

• Separately billable drugs, including EPO should be line item billed. Include the line item date of service for the administration. Reimbursement will be calculated based on the units reported on the line.

• The units reported on the line for each date dialysis (codes 821, 831, 841 and 851) was performed should not exceed one.

• Height and weight should be reported for all ESRD patients.

• A8 – Weight in kilograms

• A9 – Height in centimeters

• Report modifiers, occurrence codes, and condition codes.

• Bill must include revenue codes and CPT codes for each line of service. For example, when billing hemodialysis submit revenue code 0821 with CPT code 90999.

• The training rate includes the composite rate. Therefore, the composite rate should not be billed separately for days when training was provided.

• Do not bill for hemodialysis and peritoneal dialysis composite rates on the same claim. In this situation, you must bill a claim for each type of dialysis provided within the same calendar month. Dates of service must not overlap.


Non-contracted Medicare Advantage

The following fields are required on all Medicare Advantage claims:

• A patient’s height and weight – entered in the value amount fields for value codes A8 and A9

• CBSA – must be included in the value amount field for value code 61

Billing tips for 98943, 97140, E0720 AND E0730

The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E/M services may be reported separately using modifier 25, if the member’s condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure.

Chiropractic Manipulative Treatment: CMT is a form of manual treatment to influence joint and neurophysiological function.

When similar or identical procedures are performed, but are qualified by an increased level of complexity:

Only the definitive or most comprehensive service performed should be reported

Only one CMT service of the spinal region (procedures 98940-98942) is eligible for payment on a single date of service.

Payment is limited to one clinically indicated and medically necessary physical medicine modality or procedure code per patient, per date of service.

Payment is allowed for one clinically indicated and medically necessary extra spinal manipulation code (i.e., 98943-51) in combination with a spinal manipulation code (i.e., 98940, 98941, or 98942) per date of service.

When multiple procedures are performed at the same session by the same provider, the modifier 51 may be appended to the additional CPT codes (excluding E/M codes).


Physical Medicine and Rehabilitation: The selection of appropriate physical medicine modalities and procedures should be based on the desired physiological response in correlation to the stages of healing. In most conditions or injuries, utilization of one carefully selected modality or procedure in combination with CMT is adequate to achieve a successful clinical outcome.

97140, manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes, will not be separately reimbursed when billed with 98940-98943 (CMT) for the same region. Modifier 59 should be used with 97140 when billed with a CMT code, but performed on a different anatomical region.

It is not appropriate to bill 97124, massage, for myofascial release. For myofascial release, 97140 should be reported and is reimbursable if it is not billed with a CMT code pertaining to the same anatomical region. When reporting or billing for 97112 (neuromuscular reeducation) and 97124 (massage) as well as all other physical medicine modalities and therapeutic procedures, the details of the procedure shall be recorded in the medical record, including clinical rationale, anatomical site, description of service, and time (as required by the selected procedure code).


TENS: When found to be medically necessary, the following codes are reimbursed for TENS when billed under the following codes:

• E0720

• E0730

Billing Guide for Allergy Shots and Visit Services on the Same Day - CPT 95115

At the outset of the physician fee schedule, the question was posed as to whether visits should be billed on the same day as an allergy injection (CPT codes 95115-95117), since these codes have status indicators of A rather than T. Visits should not be billed with allergy injection services 95115 or 95117 unless the visit represents another separately identifiable service. This language parallels CPT editorial language that accompanies the allergen immunotherapy codes, which include codes 9515 and 95117. Prior to January 1, 1995, you appeared to be enforcing this policy through three (3) different means:


• Advising physician to use modifier 25 with the visit service;

• Denying payment for the visit unless documentation has been provided; and

• Paying for both the visit and the allergy shot if both are billed for.

For services rendered on or after January 1, 1995, you are to enforce the requirement that visits not be billed and paid for on the same day as an allergy injection through the following means. Effective for services rendered on or after that date, the global surgery policies will apply to all codes in the allergen immunotherapy series, including the allergy shot codes 95115 and 95117. To accomplish this, CMS changed the global surgery indicator for allergen immunotherapy codes from XXX, which meant that the global surgery concept did not apply to those codes, to 000, which means that the global surgery concept applies, but that there are no days in the postoperative global period.

Now that the global surgery policies apply to these services, you are to rely on the use of modifier 25 as the only means through which you can make payment for visit services provided on the same day as allergen immunotherapy services. In order for a physician to receive payment for a visit service provided on the same day that the physician also provides a service in the allergen immunotherapy series (i.e., any service in the series from 95115 through 95199), the physician is to bill a modifier 25 with the visit code, indicating that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.


D. Reasonable Supply of Antigens

See CMS Manual System, Internet Only Manual, Medicare Benefits Policy Manual, CMS Pub. 100-02 Chapter 15, section 50.4.4, regarding the coverage of antigens, including what constitutes a reasonable supply of antigens.

How to report multiple NDC code - and format

Billing with National Drug Codes (NDCs)

Blue Cross and Blue Shield of Texas (BCBSTX) does not require inclusion of the National Drug Code (NDC) along with the applicable Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code(s), except on claim submissions for unlisted or “Not Otherwise Classified” (NOC) physician-administered and physician-supplied home infusion therapy drugs.

BCBSTX currently accepts NDC for billing of all physician-administered and physician-supplied drugs in accordance with the NDC schedule posted on the BCBSTX Provider website under "Drugs".  Including the NDC on claims helps provide a more consistent pricing methodology for payment and will also facilitate better management of drug-associated costs. For information about how to add the additional NDC and other required elements, please refer to the BCBSTX Provider website at bcbstx.com/provider. BCBSTX will continue to accept the HCPCS or CPT code elements without NDC information (excluding unlisted or "Not Otherwise Classified" drugs).

Claims should be submitted with the exact NDC that appears on the product administered.  The NDC is found on the medication’s packaging and must be submitted in the 5digit-4digit-2digit format.  

Please note:  A drug’s container label may display less than 11 NDC digits.  An asterisk may appear in either a product code or package code as a place holder for any leading zeros.  Zeros must be added to each section to make 11 digits total when submitting the NDC code on the claim to BCBSTX.   Decimal points are acceptable in the NDC unit field.  Each container label displays the appropriate unit of measure for that drug.

Please remember the following to help ensure proper submission of valid NDCs and related information: The NDC must be submitted along with the applicable HCPCS or CPT procedure code(s).

The NDC must be in the proper format (11 numeric characters, no spaces or special characters).
The NDC must be active for the date of service.
The appropriate qualifier, unit of measure, number of units, and price per unit also must be included, as indicated below.

BCBSTX utilizes a claims payment audit process (during initial claim payment and post payment) to validate the number of units administered against the submitted charges of medications. This audit process applies to claims for medications billed with Healthcare Common Procedure Coding System (HCPCS) codes, Current Procedural Terminology (CPT®) code(s), and National Drug Code (NDC).

The audit reviews claims to identify possible overbilling errors that exceed standard dosing thresholds. It may result in denying the portion of these claims that exceeds maximum dosing levels based on the product labeling, Food and Drug Administration (FDA) dosing guidelines; peer reviewed or published medical literature for each drug.

PAPER CLAIM GUIDELINES

In the shaded portion of the line-item field 24A-24G on the CMS-1500, enter the qualifier N4 (left- justified), immediately followed by the NDC.* Next, enter the appropriate qualifier for the correct dispensing unit (F2 – international unit mainly used for Factor VIII-Antihemophilic Factor; GR – gram, generally used for ointments, creams, inhaler or bulk powder in a jar; ML – milliliter, if drug comes in a vial in liquid form; UN – unit, if drug comes in a vial in powder form and has to be reconstituted; followed by the quantity and the price per unit, as indicated in the example below.

*Note: The HCPCS/CPT code corresponding to the NDC is entered in field 24D.

EXAMPLE NDC BILLING SCENARIO : To assist you with billing with NDCs, below is an example scenario.

What was administered?

In our sample scenario, a patient received Decitabine 50 mg.

What’s on the package label? 

The NDC is found on the medication’s packaging.  The drug’s container label may display less than 11 NDC digits.  An asterisk may appear in either a product code or package code as a place holder for any leading zeros.  Each container label displays the appropriate unit of measure for that drug.

Decitabine is supplied in a single-dose 50mg per vial.  Here is an example of the NDC information that you may see when you are preparing to bill: 62856-0600-01 Dacogen, 50mg SOLR Unit of Measure = UN

What to include on the claim: When entered on your claim, the NDC must follow the 5digit-4digit-2digit format, any leading zeros must be added to each segment to make 11 digits total.  The NDC must be in the proper format (11 numeric characters, no spaces or special characters).

For our example scenario:

The NDC is 62856-0600-01 (the qualifier is N4)
The unit of measure is UN, since the drug came in a single dose and does not specify the ML The quantity (number of NDC units administered) is 1
The quantity (number of J-code units administered) is 1

The HCPCS code is J0894

NDC Billing Instructions 

Molina EDI Help Desk reports that claims are being rejected because more than one NDC code is being billed on one service line.  Below you will find instructions on billing multiple NDC codes for the same drug on a claim.

For  more  detailed  information  on  billing  NDC  codes,  please  see  the  BMS  website  at
www.dhhr.wv.gov/bms under the heading “HCPCS/Drug Codes”.

NDC’s must be configured in what is referred to as a 542 format.  The first segment must include five digits, the second segment must include four digits, and the third segment must include 2 digits.  If an NDC is missing a number on the product label, the appropriate number of zeros must be added at the beginning of the segment.  Only the NDC as specified on the label of the product that is administered to the member is to be billed.  Every NDC must be billed with an N4 qualifier before the NDC with no hyphens or spaces, the unit qualifier such as F2 (International Unit), GR (Gram), ML (Milliliter), and UN (Unit) and the NDC quantity.  Billing instructions are available at www.dhhr.wv.gov/bms & Molina Medicaid Solutions at www.wvmmis.com. Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.

Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.

Multiple NDCs 

At times, it may be necessary for providers to report multiple NDCs for a single procedure code.  For codes that involve multiple NDCs (other than compounds, see BMS website), providers must bill the procedure code with KP modifier and the corresponding procedure code NDC qualifier, NDC, NDC unit qualifier, and NDC units.  The claim line must be billed with the charge for the amount of the drug dispensed for the NDC identified on the line.  The second line item with the same procedure code must be billed utilizing KQ modifier, the procedure code units, charge and NDC information for this portion of the drug.



How to convert a 10 digit NDC to 11 digits

NDC codes are traditionally segmented into three distinct digit groups. The first identifies the manufacturer or labeler of the drug in question. The second specifies the exact dosage and form. Finally, the third segment is used to identify the “package code” assigned by the labeler – whether a package contains 20 or 50 capsules, for example.

Converting 10-digit NDC numbers to the requisite 11 digits required for claim submission is a small matter of adding a well-placed zero to one of these three segments. But NDC numbers for different drugs follow different formats. There’s a simple set of rules to help place the zero in the correct location.

·         For a 10 digit NDC in the 4-4-2 format, add a 0 in the 1st position.
·         For a 10 digit NDC in the 5-3-2 format, add a 0 in the 6th position.
·         For a 10 digit NDC in the 5-4-1 format, add a 0 in the 10th position.

In table form, that looks like this:


10-Digit Format on Package  10-Digit Format Example 11-Digit Format  11-Digit Format Example

4-4-2 9999-9999-99   5-4-2 09999-9999-99

5-3-2 99999-999-99 5-4-2 99999-0999-99

5-4-1 99999-9999-9 5-4-2 99999-9999-09



Note that the resulting 11-digit NDC number to be used in the bill always follows a 5-4-2 pattern.

One more thing to remember: The hyphens in this table are used, only, to illustrate the segmentation inherent to the NDC format. When reporting a NDC on a claim form, NEVER use hyphens.


Billing with National Drug Codes

BCBSTX reimburses claims submitted with National Drug Code (NDC) in accordance with the NDC Fee Schedule posted on the BCBSTX provider website under "Drugs." To locate this information, click the Standards & Requirements tab, then select General Reimbursement Information, enter password, then scroll down to the Reimbursement Schedules and Related Information area, then go to Professional or Ancillary (as appropriate) and select the Blue Choice PPOSM and HMO Blue Texas Schedules offering, then select 2014 Schedules effective July 1, 2014, then select Drugs. The NDC Fee Schedule is updated monthly on the first of each month.

Lower-cost generic medications may be reimbursed with a larger margin compared to higher-cost generic and brand medications. Effective June 1, 2014, BCBSTX revised the methodology utilized for determining the allowables for Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®’) codes associated with multiple NDCs, including vaccines. The HCPCS or CPT code allowable generally will be equivalent to the lowest NDC allowable associated with the HCPCS or CPT code.

When drugs are billed under the medical benefit on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims, it is important to include NDCs and related data. Using NDCs on medical claims facilitates more accurate payment and better management of drug costs based on what was dispensed. Physicians and ancillary providers are encouraged to include NDC information on claims.

BCBSTX requires inclusion of the NDC along with the applicable HCPCS or CPT code(s) on claim submissions for unlisted or “Not Otherwise Classified” (NOC) physician or ancillary provider administered and supplied drugs. BCBSTX will continue to accept the HCPCS or CPT code elements without NDC information (excluding unlisted or "Not Otherwise Classified" drugs).

As a reminder, when submitting NDCs on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims to BCBSTX, you must also include the following related information:

• The applicable HCPCS or CPT code
• Number of HCPCS/CPT units
• NDC qualifier (N4)

• NDC unit of measure (UN – Unit, ML – Milliliter, GR – Gram, F2 – International Unit)
• Number of NDC units (up to three decimal places)
• Your billable charge/price per unit

Attention electronic claim submitters: If you have converted to ANSI 5010, there should be no additional software requirements when NDCs are included on electronic claims. However, please verify with your software vendor to confirm that your Practice Management System accepts and transmits the NDC data fields appropriately. If you use a billing service or clearinghouse to submit electronic claims on your behalf, please check with them to ensure that NDC data is not manipulated or dropped inadvertently.


Prevnar Immunization 

Effective 12/30/2011 Prevnar 13® is available for WV Medicaid members over the age of 50. Prevnar 13® is FDA approved for adults 50+ years of age to help prevent pneumococcal pneu-monia, meningitis, and bacteremia caused by 13 strains of S pneumonia. CPT code 90670 is to be billed for adult vaccinations; the reimbursement includes the cost of administration – the im-munization administration codes are not to be billed separately for adult vaccines. Prevnar 13® is currently available for children up to the age of 6 through the Vaccines for Chil-dren (VFC) Program.  As with all VFC vaccines, bill the administration code with your charge for the service and the vaccine code with the SL modifier to indicate the vaccine was provided under
the VFC Program at no cost.

billing Medicare screening CPT with E & M code

MEDICARE SCREENING SERVICE AT THE TIME OF COVERED E/M SERVICES

Medicare will reimburse separately for covered screening services (e.g., G0101, Q0091) when performed at the same encounter as a covered E/M service, such as a problem-oriented visit (codes 99201-99215). The level of E/M service reported is based solely on the evaluation of the problem.

Example : Covered problem-oriented visit reported with a screening pelvic examination (G0101) and collection of a screening Pap smear specimen (Q0091).

Bill to :	CPT/HCPCS Code(s)	ICD-9 Code(s)	Charge
Medicare	99213-25	Problem diagnosis	$61.20
	G0101-GA	V76.2, V76.47, V76.49, or V15.89	$34.60
	Q0091-GA	V76.2, V76.47, V76.49, or V15.89	$40.00
Patient	N/A	N/A	$135.80

The GA modifier indicates that an ABN has been signed. Modifier 25 indicates that the E/M service was significant and separately identifiable and not part of the pelvic examination or collection of the Pap smear.

The patient is not billed for her portion until Medicare has processed the claim. The diagnosis code for the patient’s problem, signs or symptoms should be linked to the E/M service (99213). The level of service for the E/M visit will depend on what was performed and documented.

ICDs for OB/GYN, Neurology, Personal History, Foreign Body

OB/GYN 

Several new codes have been added that are related to obstetrics and gynecological services (OB/GYN). See the 2011 ICD-9-CM manual for additional information on the following additions:
•    Congenital Anomalies of the Uterus (752.31 thru 752.39)
•    Congenital Anomalies of Genital Organs (752.43 thru 752.47)
•    Personal History of Vaginal or Vulvar Disease (V13.23 or V13.24)
•    Intrauterine Contraceptive Device Management (V25.11 thru V25.13)
•    Multiple Gestation Placenta Status (V91.00 thru V91.99) 

Neurology

Seven new Symptoms, Signs and Ill-Defined Conditions diagnoses were added in order to describe cognitive deficits in patients who have suffered a traumatic brain injury (TBI). The new codes include the following:
•    799.50 – Unspecified signs and symptoms involving cognition
•    799.51 – Attention or concentration deficit
•    799.52 – Cognitive communication deficit
•    799.53 – Visuospatial deficit
•    799.54 – Psychomotor deficit
•    799.55 – Frontal lobe and executive function deficit
•    799.59 – Other signs and symptoms involving cognition 

Personal History
Eight new personal history codes (V13.62 thru V13.69) were added this year to document corrected congenital conditions (See the ICD-9 manual for more detailed definitions). These codes ought to be used in addition to the diagnosis for the condition itself. For example, a child with a surgically repaired cleft would be documented as 749.00, cleft palate, and V13.64,
personal history of corrected congenital malformations of eye, ear, face and neck.

Foreign Body

Several new codes were added this year in regards to foreign bodies. Providers must distinguish between foreign bodies that have been fully removed, as opposed to foreign bodies that remain in the body. With retained foreign bodies, code selection is based on the type of foreign body present. The new codes are listed as: personal history of retained foreign body fully removed (V15.53), and retained foreign body status (V90.01 thru V90.89).

Taxonomy guide for CMS 1500 from wellcare insurance

Wellcare -Taxonomy Guide

In accordance with SNIP level 4 edits, a valid taxonomy is a requirement for all providers when submitting both paper and electronic claims. This guide will provide basic information to further instruct and educate all providers in assistance with taxonomy submittals.

Taxonomy code is constructed of 10 digits- numeric and alpha: (see example 1)

Placement of Taxonomy and Qualifier

Tips:
 Qualifiers are to be included on both paper and electronic claims for proper submission of claims
 Provider should be billing with the taxonomy that is filled with DCH

CPT code - 99201, 99202, 99203, 99204 - 99205 - office visit code.

CPT CODE and Description

CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.

CPT 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

Changes in the E & M code - 99201, 99202, 99203, 99204, 99205 - Update of Year 2021

AMA has revised the definitions for E/M codes 99202–99215 in the Current Procedural Terminology (CPT) 2021 codebook. The existing guidelines were developed in 1995 and 1997 and remain in effect for all other E/M services determined by history, exam, and medical decision-making (MDM).

What do the new changes mean to you? In 2021, for new and established office and other outpatient services reported with codes 99202–99215, a clinician may select the code on the basis of time or MDM.

There are three elements in MDM, and two of three are required. These elements are the number and complexity of problems addressed, amount and/or complexity of data to be reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management.

History and exam don't count toward level of service

Physicians, advanced practice registered nurses, and physician assistants won't use history or exam to select what level of code to bill for office visits 99202–99215, as they did in the past. They need only document a medically appropriate history and exam. The history may be obtained by staff members and reviewed by the billing practitioner.

While specific history and exam requirements disappear for office visit codes, they remain for all other types of visits, selected on the basis of history, exam, and MDM, such as hospital services, nursing facility services, and home and domiciliary care. So, say goodbye to "all other systems reviewed and negative" in office notes, but keep it handy for those other E/M codes.

 All time spent caring for the patient on a particular day counts

This includes all time spent on the day of service, including preparing to see the patient, seeing the patient, phone calls or other work done after the visit (if not billed with a care management or other CPT code), and documenting in the medical record. The AMA developed new guidelines for using time for office and other outpatient services. For codes 99202–99215, count all of the face-to-face and non–face-to-face time spent by the billing clinician on the day of the visit. Counseling does not need to be more than 50% of the total time

Do not include any staff time or time spent on any days before or after the visit. This allows clinicians to capture the work when a significant amount of it takes place before or after the visit with the patient, and to bill for it on the day of the visit.

According to the 2021 CPT codebook, physician or other qualified healthcare professional time includes the following activities*:

preparing to see the patient (eg, review of tests)

obtaining and/or reviewing separately obtained history

performing a medically appropriate examination and/or evaluation

counseling and educating the patient/family/caregiver

ordering medications, tests, or procedures

referring and communicating with other healthcare professionals (when not separately reported)

documenting clinical information in the electronic or other health record

independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver

care coordination (not separately reported)

*American Medical Association. CPT 2021 Professional Edition. AMA; 2020:8.

The codes now have time ranges, in place of a single threshold time.

Code Time range Code Time range

99202 15-29 minutes 99212 10-19 minutes

99203 30-44 minutes 99213 20-29 minutes

99204 45-59 minutes 99214 30-39 minutes

99205 60-74 minutes 99215 40-54 minutes

Fee schedule update on office visit CPT code (99201 - 99205)

FL Medicare Fee Schedule

CPT  2020  2021  Difference

99202  $76.34  $67.04  -12%

99203  $108.33  $103.83 -4%

99204  $166.38  $156.50 -6%

99205  $210.45   $206.77 -2%

Time Period for CPT 99201 - 99205

CPT 99201 - 10 Minute
CPT 99202 - 20 Minute
CPT 99203 - 30 Minute
CPT 99204 - 45 Munute
CPT 99205 - 60 Minute

Office Visit coding will change in 2021

• Visits will be coded based on either Time or Medical Decision-Making

• 99201 deleted

• Medically appropriate History and Examination must still be documented

• New code for prolonged services of 15-30 minutes

SELECTING CORRECT CPT CODING GUIDELINES

Select the appropriate code based on the level of service provided when you are seeing a new patient for initial evaluation of a neuromusculoskeletal condition or injury.


Documentation in the clinical record must support the level of service as coded and billed. The Key Components - History, Examination, and Medical Decision Making - must be considered in determining the appropriate code (level of service) to be assigned for a given visit.

• Select code that best represents the services furnished during the visit.

• A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer.

• Reviewers may assist with selecting codes, however, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

• Ensure that medical record documentation supports the level of service reported to a payer.

• The volume of documentation does not determine which specific level of service is billed.

• Remember - medical necessity is the overarching criteria for coverage.

Note: for new patients, all three key components must meet or exceed the above requirements for a given level of service; for established patients, two of the three key components must meet or exceed the requirements.

Time – Now and in 2021 

2020 –

 • Evaluation and Management services can be coded based on time only if visit is dominated by counseling and coordination of care – and only face-to-face time counts

• For Medicare, during Public Health Emergency, telehealth visits may be coded based on time even if not dominated by counseling and coordination of care

 2021 –

 • Office visits level will be determined either by time or by revised Medical Decision-Making criteria 

• Time is not just face-to-face time

Office visit codes - 2021 - Time - What Counts? 

• preparing to see the patient (eg, review of tests) 

• obtaining and/or reviewing separately obtained history 

• performing a medically appropriate examination and/or evaluation

• counseling and educating the patient/family/caregiver 

• ordering medications, tests, or procedures 

• referring and communicating with other health care professionals (when not separately reported) 

• documenting clinical information in the electronic or other health record • independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver • care coordination (not separately reported)


Patient Status: New or Established?

• A patient never before seen in the practice/specialty OR not seen by you or one of your partners of the same specialty in more than 3 YEARS

– E/M codes for NEW patients

• 99201, 99202, 99203, 99204, 99205
• Preventative codes – 99384, 99385, 99386, 99387
• A patient who has been seen in the office by you or one of your partners of the same specialty within the last 3 YEARS.

– E/M codes for ESTABLISHED patients

• 99211, 99212, 99213, 99214, 99215
• Preventative codes – 99394, 99395, 99396, 99397

99201: requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

• 99202: requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.

• 99203: requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to- face with the patient and/or family. 64 

99204: requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.

• 99205: which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 




The 99201 code has more specific requirements than 99211 when it comes to elements of the history, purgative and medical decision making. In addition, 99201 is not to be used for nursing visits, as the physician needs to see the patient and establish a care plan before nurses' visits can be billed.



Established Patient


99212: requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

• 99213: requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. 


99214: requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

• 99215: requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. 


Evaluation and Management Services

Requirements of E&M Documentation

• 3 Components of Documentation:

– History

• Chief complaint; past medical, social, and family histories; ROS

– Exam
– Medical Decision Making

• Number of dx or tx options; amount of data; risk Subjective (patient-provided)

– Chief Complaint
– History of the present illness (HPI)
– Review of systems (ROS)
– Past, family, social history (PFSH).

Examination

– Expanded Problem-Focused – for 99202 or 99213

• a limited examination of the affected body area or organ system and any symptomatic or related body area(s) or organ system(s). Minimum 2 body areas/organ systems examined.

– Detailed – for 99203 or 99214

• an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s). Minimum 4 body areas/organ systems examined with depth in one area/system.

– Comprehensive – for 99204, 99205 or 99215

• a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s). Minimum 8 organ systems examined.

4 Types of Examination based on 1997 Guidelines:

– Problem Focused – should include performance and documentation of one to five elements identified by a bullet in one or more organ system(s) or body area(s).

– Expanded Problem-Focused – should include performance and documentation of at least six elements identified by a bullet in one or more organ system(s) or body area(s).

– Detailed – should include performance and documentation of at least twelve elements identified by a bullet in two or more organ system(s) or body area(s).

– Comprehensive – should include performance and documentation of at least eighteen elements identified by a bullet in nine or more organ system(s) or body area(s).

Time-Based Coding
99201 = 10 minutes
99202 = 20 minutes
99203 = 30 minutes
99204 = 45 minutes

99205 = 60 minutes

Can time alone be used to select an E/M code?

Answer: 
In certain circumstances, time can be used as the key or controlling factor for selecting an evaluation and management (E/M) code. When counseling and/or coordination of care dominates (e.g., more than 50 percent) the physician/patient encounter (e.g., face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), the time may be considered the key or controlling factor to qualify for a particular level of E/M service. The extent of the counseling and/or coordination of care must be documented in the medical record.

Information on E/M guidelines concerning documentation guidelines is available on the CMS Medicare Learning Network website.

Can time be used as a basis for E/M code selection in regards to add-on psychotherapy services?

Answer: 
No. Time may not be used as the basis of E/M code selection. The E/M code billed should be chosen based on the elements of the history and exam and decision making required for the complexity and intensity of the patient's condition. Additionally, prolonged services may not be reported when psychotherapy with E/M add-on codes 90833, 90836, 90838 are reported. For a listing of code definitions, please see the current CPT codebook.

If a provider sees a new patient and performs a comprehensive history, does the comprehensive history warrant submitting a higher level service?

Answer:
It depends. The level of evaluation and management (E/M) service is dependent on three key components (history, examination and medical decision making). Performance and documentation of one component (e.g., history) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.


If an established patient presents to the office for a visit with a non-physician practitioner (NPP), and during the encounter the patient has a new problem/condition, can this service be submitted 'incident to'? What if the NPP only orders tests, but does not establish a plan of care?

Answer:
No, there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment. This service must be submitted under the NPP’s NPI number. A service cannot be submitted 'incident to' even when the NPP only orders diagnostic or laboratory tests, unless the physician provides a face-to-face encounter and establishes the course of treatment (e.g., need for X-ray, apply ice, etc.) during the encounter (must be documented by the physician)

What date of service would I use for an Evaluation & Management (E/M) visit that begins on one day and ends on the next?


Response: It would be appropriate to use the date the service was completed as the date of service on the claim. The medical record must document the date of service billed. 


What is the definition of a 'new patient' when selecting an E/M CPT code?

Answer:  

'New patient' means a patient who has not received any professional services, such as an E/M service or other face-to-face service (e.g., surgical procedure), from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a three year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed), then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient, does not affect the designation of a new patient.

CPT Code 99205 OFFICE OUTPATIENT NEW 60 MINUTES

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity.

 Physicians typically spend 60 minutes face-to-face with the patient and/or family.


Requirement for CPT code 99205

Comprehensive history includes:

• Chief complaint/reason for admission
• Extended history of present illness
• Review of systems directly related to the problem(s) identified in the history of present illness
• Medically necessary review of ALL body systems’ history
• Medically necessary complete past, family and social history
• Four or more elements of the HPI or the status of at least three (3) chronic or inactive conditions, noting that medical necessity is ALWAYS the overarching criterion.

HPI – History of Present Illness: 

A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. 
Descriptions of present illness may include:
• Location
• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs/symptoms significantly related to the presenting problem(s)

Chief Complaint: The Chief Complaint is a concise statement from the patient describing:

• The symptom
• Problem
• Condition
• Diagnosis
• Physician recommended return, or other factor that is the reason for the encounter

Review of Systems: An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purpose of Review of Systems the following systems are recognized:
• Constitutional (i.e., fever, weight loss)
• Eyes
• Ears, Nose, Mouth Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary
(skin and/or breast)
• Neurologic
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

Past, Family, And/or Social History (PFSH): Consists of a review of the following:
• Past history (the patient’s past experiences with illnesses, operations, injuries and treatments) 
• Family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk)

• Social History (an age appropriate review of past and current activities)

Billing with Preventive code

A preventive E/M visit with a problem-oriented service. Use a CPT preventive medicine service code (99381-99397) plus the appropriate E/M code (99201-99215) with modifier 25 attached to show that the services were significant and separate. Link the appropriate ICD-9 code(s) to each CPT code to help distinguish the services. Note that not all payers will reimburse for both preventive and problem-oriented services on the same date

The preventive E/M visit with a problem-oriented service When a patient comes into the office for a routine preventive examination, and has significant new complaints (e.g., chest pain or irregular bleeding) and, in some instances, a new or established chronic condition (e.g., hypertension or type-II diabetes), the visit becomes a  combination of preventive and problem-oriented care. As long as the problem-oriented service is clearly documented and distinct from the documentation of the preventive service, CPT suggests submitting a preventive medicine services code (99381-99397) for the routine exam, and the appropriate office visit code (99201-99215) with modifier –25,” significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service," attached to the problem-oriented service. It's also especially important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between preventive and problem-oriented services

Centers of Medicare and Medicaid Services (CMS) in our time identify the current procedural terminology as the level one of the healthcare common procedure coding system. The cpt code 99201 denotes problem focused in the history and physical exam sections of records of new office patients.

In general, the CPT codes range from 99201 to 99499 indicates evaluation and management.  The current procedural terminology code 99201 to 99215 denotes office or other outpatient services. You have to know about these codes when you have geared up for enhancing your proficiency in the current procedural terminology day after day.

The cpt code used for indicating the level 1 new patient office visit is 99201.  As the lowest level care for every new patient in the medical office, 99201 assists all healthcare professionals and people who work in the medical sector to know about the new patient office visit directly. 

The overall health problems of these patients are minor or self-limited. The most competitive price of treatment for patients who have 99201 for new office visit nowadays attracts people who think about the cost of the initial healthcare treatment.  

There are three important elements in the documentation associated with the level 1 new patient office visit 99201. These elements are problem focused history, problem focused exam and straightforward medical decision making.  If there is current procedural terminology based on time, then patients consult with medical professionals face to face and use this appropriate documentation.

Beginners to CPT these days seek the definition of new patient. They have to keep in mind that a new patient is one who has not received any healthcare treatment from any medical professional within the past three years. An established patient is a patient who has received professional medical services from physicians in the same group within the past three years.    People who focus on the history, exam, medical decision making and typical face to face time in the new patient office visit level 1 record can get the complete details about healthcare issues of the patient. 

Q: How should the initial OB visit be reported?

A: Per ACOG guidelines, if the OB record is not initiated, then the office place of service visit should be reported separately by using the appropriate E/M CPT code (99201-99215, 99241-99245 and 99341-99350) and ICD-9-CM diagnosis code of V72.42 to be used on or before date of service September 30, 2015 or ICD-10-CM diagnosis code of Z32.01 to be used on or after date of service October 01, 2015. If the OB record is initiated during the confirmatory visit, then the confirmatory visit becomes part of the global OB package and is not reported separately.

Evaluation and Management Service Codes - General (Codes 99201 - 99499)

A. Use of CPT Codes Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management services. Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice.

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

B. Selection of Level Of Evaluation and Management Service

Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection C. Any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering UPIN/PIN.

"Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met.

CPT code 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.

CPT code 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

CPT code 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.

CPT code 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.


Evaluation & management tips: Office or other outpatient services, new patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History,
2. Examination, and
3. Medical decision-making.
When billing office or other outpatient services for new patients, all three key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.
Current Procedural Terminology� codes and requirements

99201 - 10 minutes (average)
• Problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system
• Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):
• Minimal number of diagnoses or management options
• None or minimal amount and/or complexity of data to be reviewed
• Minimal risk of significant complications, morbidity and/or mortality

99202 - 20 minutes (average)
• Expanded problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem pertinent review of systems
• Expanded problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
• Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):
• Minimal number of diagnoses or management options
• None or minimal amount and/or complexity of data to be reviewed
• Minimal risk of significant complications, morbidity and/or mortality

99203 - 30 minutes (average)
• Detailed history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Extended review of systems
• Pertinent past, family and/or social history
• Detailed examination. Documentation needed:
• Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
• Medical decision making that is of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Limited number of diagnoses or management options
• Limited amount and/or complexity of data to be reviewed
• Low risk of significant complications, morbidity and/or mortality

99204 - 45 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family and/or social history
• Comprehensive examination. Documentation needed:
• A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or 8 or more organ system(s)
• Medical decision making that is of moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99205 - 60 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family and/or social history
• Comprehensive examination. Documentation needed:
• A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality

Coding Question: Is it required by Medicare and Medicaid to have a referring physician in order to be able to bill for a new patient evaluation? If so, what should one do if the patient self refers himself/herself to you because of reputation/friend etc.?

Coding Response: The CMS definition for a new patient states that, “such a patient would be regarded as a new patient, a patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the last three years.” Therefore, any patient presenting him/herself to you would be regarded as a new patient. Effective January 1, 2010, CMS has eliminated payment for the office or other outpatient consultation codes 99241- 99245. The office and other outpatient visit codes for new patients (99201- 99205) are still recognized for reimbursement by CMS and may be used to report any new patient being seen in your practice. As a result of these changes, there is no distinction between a patient who is referred by a physician or one who is self referred; for Medicare they are both considered a new patient.  The E/M codes that can be used are CPT codes 99201 – 99205.


CPT code 99241: Office consultation for a new or established patient, which requires these 3 components:  a problem focused history, a problem focused examination, and straightforward medical decision making.

CPT code 99242: Office consultation for a new or established patient, which requires these 3 components:  an expanded problem focused history, an expanded problem focused examination, and straightforward medical decision making.

CPT code 99243: Office consultation for a new or established patient, which requires these 3 components:  a detailed history, a detailed examination, and medical decision making of low complexity.

CPT code 99244: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.

CPT code 99245: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of high complexity.


E & M code questions

Q: Will Oxford separately reimburse for the office E/M service performed with the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional? 

A: No, Oxford does not separately reimburse an E/M service in addition to the Injection service. When an E/M injection service is submitted for the same member on the same date of service, there is a presumption that the E/M service represents the physician work that is part of the Injection procedure. CPT indicates therapeutic and diagnostic injection service(s) typically require(s) direct physician supervision for any or all purposes, of patient assessment, provision of consent, safety oversight, intraservice supervision of staff, preparation and disposal of the injection materials, and the required practice training of staff for competency in the administration of Injections/Infusions. 

Example: The following example describes an E/M service that is not separately reimbursed from a therapeutic and diagnostic injection: A physician or nurse sees a patient in the office for a scheduled Injection, asks about prior allergic reactions, instructs on post-injection care of the Injection site and administers the Injection. The E/M service is integral to the Injection and is not separately reimbursable.


Q: Will Oxford separately reimburse for an office E/M service when provided in other than POS 19, 21, 22, 23, 24, 26, 51, 52, and 61 if a significant, separately identifiable E/M service is performed in addition to the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional?

A: Yes, Oxford will separately reimburse for an E/M service (other than CPT 99211) unrelated to the physician work associated with the Injection service (CPT 96372-96379) when reported with a modifier 25. Refer to Q&A #2 for a description of the physician work typically included in the allowance for the therapeutic and diagnostic Injection service. When an E/M service and an Injection or Infusion service are submitted for the same member on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service.


Example: The following example describes an E/M service that is separately identifiable from a therapeutic and diagnostic Injection: A physician evaluates a patient’s symptoms, diagnoses a serious streptococcal infection, and treats with injectable penicillin. The diagnostic process is separately identifiable from the process of the injection. The E/M service (other than CPT code 99211) should be reported with modifier 25 and is reimbursed separately from the therapeutic Injection code and the drug code for the penicillin.



BCBS Guidelines for new patient 99201 - 99203 - 99205

Medical Examinations and Evaluations with Initiation/Continuation of Diagnostic and Treatment Program:

CPT codes 92002-92014 are for medical examination and evaluation with initiation or continuation of a  diagnostic and treatment program. The intermediate services (92002, 92012) describe an evaluation of a new or existing condition complicated with a new diagnostic or management problem with initiation of a diagnostic and treatment program. They include the provision of history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated, including mydriasis for ophthalmoscopy. The comprehensive services include a general examination of the complete visual system and always include initiation of diagnostic and treatment programs. These services are valued in relationship to E/M services, though past Medicare fee schedule work relative value unit cross walks from ophthalmological services to E/M no longer exist. Nonetheless, the valuations provide some understanding of the type of medical decision-making (MDM) that might be expected. 92002 is closest to 99202 (low or moderate MDM) and 92004 is between 99203 and 99204 (moderate to high MDM).

Code 92012 is closest to 99213 (low to moderate MDM) and 92014 is closest to 99214 (moderate to high MDM).These services require that the patient needs and receives care for a condition other than refractive error.They are not for screening/preventive eye examinations, prescription of lenses or monitoring of contact lenses for refractive error correction (i.e. other than bandage lenses or keratoconus lens therapy). There must be initiation of treatment or a diagnostic plan for a comprehensive service to be reported. An intermediate service requires initiation or continuation of a diagnostic or treatment plan.  Follow-up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014. For example, care of a patient who has a history of self limited allergic conjunctivitis controlled by OTC antihistamines who is being seen primarily for a preventive exam should not be  reported using 92002-92014. A patient who has an early or incidentally identified cataract and is not being seen for visual disturbance related to the cataract, but is being seen primarily for refraction or screening, is not receiving a service reported with 92002-92014. eye examination for diabetics is considered a diagnostic treatment plan and is correctly reported with the most appropriate CPT code based upon the level of services.

Reporting screening, preventive or refractive error services with codes 92002-92014 is misrepresentation of the service, potentially to manipulate eligibility for benefits and is fraud. If the member has no coverage for a routine eye exam or lens services, it is appropriate to inform the member of their financial responsibility. Do not provide the member with a receipt for 92002-92014 if providing a non-covered preventive/screening Routine Eye Exam service as the member may seek clarification from BCBSRI and these services are typically covered.

NEW PATIENT- Same Specialty and Subspecialty:

CPT defines when a patient is new or established. It uses terms "exact same specialty" and "exact same subspecialty". CPT also states "When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialty as the physician." BCBSRI uses American Boards of Medical Specialties or American Osteopathic Association Boards to define physician specialties. In some cases BCBSRI creates additional specialties at our sole discretion. The team practice concept in the same group as defined for APRNs/PAs also could apply to other disciplines/licensure classes in reporting E/M. In general, if two or more disciplines may report E/M, it applies. For example, optometry and ophthalmology in the same group would be considered the exact same specialty/subspecialty. However, a clinical social worker and psychiatrist in the same group would not be so considered Routine Ophthalmological Evaluation, Including Refraction: HCPCS Codes S0620 and S0621 are used for these services for the new and  stablished patient, respectively.

If during the course of an evaluation it is necessary to initiate a treatment or diagnostic program, the appropriate CPT code (92002-92014) may be reported instead. An insignificant or trivial problem/abnormality that is encountered in the process of performing the routine examination and which does not require significant additional work would not warrant use of the CPT code. The HCPCSII codes, S0620-S0261, direct the claim to be correctly adjudicated based upon the member’s coverage for preventive and refraction exams. These services include screening for glaucoma or other eye disease consistent with the standards of care for a complete preventive eye examination. In the instance where a patient is treated for a condition that would allow the reporting of 92002 or 92004, but the higher level (based upon allowance) service correctly reported is the Routine Exam, S0620-S0621 may be reported. In the case where a member does not have benefits for the routine exam, as verified with BCBSRI members, the CPT should be reported and the member may be charged the difference between the charge for the non-covered routine service(s) and the charge (not allowance) for the covered service.

Refraction:

CPT 92015 describes refraction and any necessary prescription of lenses. Refraction is not separately reimbursed as part of a routine eye exam or as part of a medical examination and evaluation with treatment/diagnostic program. 


Evaluation and Management Codes

In a health department environment, a limited range of E & M codes would be submitted including 99201, 99202, 99203, 99211, 99212 and 99213. These codes are used for new patients (99201, 99202, 99203) and established patients (99211, 99212, 99213) when treated in an office and/or outpatient setting.

There also are preventive medicine codes that may be used to report the preventive medical evaluation of infants, children and adults. These visits will not have a presenting problem as they are “well” preventive visits. These codes are defined as a new or established patient and by age.


The codes for new patients are 99381-99387 and for established patients 99391- 99397. If the age of the patient does not match the age described in the code, the claim will be rejected. According to AMA CPT® and BCBSKS definitions, a new patient is a patient who hasn’t been seen for three or more years in a practice. An established patient is a patient who has been treated in the practice within the past three years. When a patient makes an appointment, a reason for the encounter needs to be established. Per AMA CPT®, a “concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient’s words.” At this point a diagnosis is established for the encounter. The reason for the encounter will be assigned an ICD-10 code to correlate with the AMA CPT® code. An ICD-10 code defines what prompted the encounter and the AMA CPT® code defines what service was performed during the encounter.

The different levels of office visits are determined by the following components:

• History

• Review of systems, personal and/or family history

• Examination

• Medical decision making

• Counseling

• Coordination of care

• Nature of presenting problem

• Time *

*In a health department setting, time probably would not be a factor in determining the level of E & M code.

However, the first four components – history, review of systems, examination, medical decision making – are key components to selecting the level of E & M
code.

The extent of the history is determined by the clinical opinion of the performing provider based on the patient’s complaints. The levels of history most likely to be seen in a health department setting are problem focused or expanded problem focused.

Per AMA CPT® guidelines they are defined as follows:

• Problem focused: chief complaint; brief history of present illness or problem.

• Expanded problem focused: chief complaint; brief history of present illness; problem pertinent system review

• Detailed: chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, and/or social history directly related to the patient’s problems.

The next step is to decide on the appropriate examination level. Once again, this is determined by the performing provider. The level of examinations which  would be expected to be seen in a health department setting is as follows per CPT® guidelines:

• Problem focused: a limited examination of the affected body area or organ system.

• Expanded problem focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

• Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

The third key component is to determine the complexity of the medical decision making as determined by the performing provider. In a health department setting the two levels of medical decision making that would routinely be seen are straightforward and low complexity.

• Straightforward: minimal number of diagnoses or management options; minimal or no amount and/or complexity of data to be reviewed; minimal risk of complications and/or morbidity or mortality would be involved.

• Low complexity: limited number of diagnoses or management options; limited amount and/or complexity of data to be reviewed; low risk of complications and/or morbidity or mortality would be involved.

After selecting the level of office visit that is to be submitted for reimbursement, it needs to be determined what additional services, if any, were provided to the patient, i.e., injections and or immunizations.

The CMS HCPCS code list would be used to locate drugs to supplement the AMA CPT® codes as the second level of the coding system.

After selecting the level of office visit to be submitted, and if applicable, a second level (HCPCS) code; a diagnosis code must be assigned. Per AMA CPT®
guidelines, the primary diagnosis is what prompted the encounter as described in the patient's own words.


Per the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) guidelines, the primary diagnosis is what prompted the encounter as described in the patient’s own words


Eligible Providers For Reporting E&M Codes

Evaluation &Management were designed to classify services provided by physicians in evaluating patients and managing their medical care and these codes are drive much of revenue in physician practices as a result these codes are vulnerable under third party auditor scrutiny.

For auditing perspective, the visit notes need to satisfy the following question,
▪ Does the documentation truly justify the services rendered?
▪ Are those services medical necessary for the diagnosis treated?
▪ Whether the provider eligible to bill E&M?

E&M codes are limited only by physician and specific non-physician practitioner (NP, PA, CNS, CNM) and other qualified health care professional are excluded under statutory regulation


The below providers are eligible to bill E&M codes

1. All physicians
2. Non-Physician practitioners
a. Nurse practitioner (NP)
b. Clinical nurse specialist (CNS)
c. Certified nurse midwife (CNM)
d. Physician assistant (PA)

As per Social Security Act, Physician & NPP’s (NP, CNS, CNM, PA) alone eligible to provide Management services like preparing care plan, Treatment plan


PROPOSED PAYMENT FOR OFFICE/OUTPATIENT BASED E/M VISITS

Proposing a single PFS payment rate for E/M visit levels 2-5 (physician and non- physician in office based/outpatient setting for new and established patients).
Proposing a minimum documentation standard, for Medicare PFS payment purposes, wherein, for an office/outpatient-based E/M visit, practitioners would only need to document the information to support a level 2 E/M visit (except when using time for documentation).


MEDICAL DECISION MAKING OR TIME

CMS proposed to allow practitioners to choose, as an alternative to the current framework specified under the 1995 or 1997 guidelines, either MDM or time as a basis to determine the appropriate level of E/M visit.

This would allow different practitioners in different specialties to choose to document the factor(s) that matter most, given the nature of their clinical practice.

It would also reduce the impact Medicare may have on the standardized recording of history, exam and MDM data in medical records, since practitioners could choose to no longer document many aspects of an E/M visit that they currently document under the 1995 or 1997 guidelines for history, physical exam and MDM.


CPT CY 2018 Non-facility payment rate Proposed CY 2019 Non-facility payment rates
99201 $45 $44
99202 $76 $135
99203 $110 $135
99204 $167 $135
99205 $211 $135


CPT CY 2018 Non-facility payment rate Proposed CY 2019 Non-facility payment rates

99211 $22 $24
99212 $45 $93
99213 $74 $93
99214 $109 $93
99215 $148 $93