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Evaluation

By Mary Lawson,2014-06-27 06:04
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Evaluation Evaluation Evaluation Evaluation

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    Evaluation & Management (E&M) 1

    thThe Physicians’ Current Procedural Terminology 4 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.

    Psychotherapy Services Refer to the Psychiatry section in the appropriate Part 2 manual for

    information about billing E&M services in conjunction with

    psychotherapy services.

    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).

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    Established Patient An established patient is one who has received professional services Reimbursement from the provider within the past three years.

    Providers On Call If a provider is on call or covering for another provider, any service

    rendered must be classified as it would have been by the provider who

    is not available.

    E&M Services The following CPT-4 codes for E&M services are separately Separately Reimbursable 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.

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     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.

    Frequency Restrictions The frequency restriction for CPT-4 codes 99211 99214 may be

    exceeded with medical justification. Providers must submit the medical justification with the original claim when established E&M visits exceed six in 90 days. Providers must document that the patient’s acute or chronic condition requires frequent visits in order to monitor their condition with the goal of decreasing hospitalizations.

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    E&M Services The following CPT-4 codes for E&M services are not separately 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 Prolonged services include outpatient services (CPT-4 codes E&M Services 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 To report prolonged outpatient E&M services, CPT-4 codes 99354 CPT-4 Code 99354 (office or outpatient setting; first hour) must be billed in conjunction

    with one of the following E&M codes.

    CPT-4 Code Description

    99201 99205 Office or other outpatient visit

    99212 99215

    99241 99245 Office or other outpatient consultation

    99324 99328 Domiciliary, rest home, or custodial care

    99334 99337 visit

    99341 99345 Home Visit

    99347 99350

    90809, 90815 Outpatient psychotherapy with

     E&M component

    CPT-4 Code 99355 To report additional prolonged outpatient E&M services, CPT-4 code

    99355 (each additional 30 minutes) must be billed in conjunction with

    code 99354.

    Billing Calculations CPT-4 codes 99354 and 99355 are subject to the least restrictive

    frequency limitation as the required companion code. To calculate the

    amount of time that is payable for prolonged outpatient services, take

    the total face-to-face time and subtract the time of the primary E&M

    service. The following table may be used to calculate billing for

    prolonged outpatient E&M services.

    .

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    Time of E&M

    visit code Each additional

    not included First hour 30 minutes

    Less than 30

    minutes Not reported Not reported

    30 74 minutes 99354 Not reported

    75 104 minutes 99354 99355

    105 134 minutes 99354 99355 (quantity of 2)

    135 164 minutes 99354 99355 (quantity of 3)

    165 194 minutes 99354 99355 (quantity of 4)

    Inpatient Services To report prolonged inpatient E&M services, CPT-4 codes 99356

    CPT-4 Code 99356 (inpatient setting; first hour) must be billed in conjunction with one of

    the following E&M service codes:

    CPT-4 Code Description

    99221 99223 Initial hospital care and subsequent

    99231 99233 hospital care

    99251 99255 Inpatient consultation

    99304 99310 Nursing facility services

    90822, 90829 Inpatient psychotherapy with E&M

     component

    CPT-4 Code 99357 To report prolonged inpatient E&M services, CPT-4 codes 99357

     (each additional 30 minutes) must be billed in conjunction with code

    99356.

    Billing Calculations CPT-4 codes 99356 and 99357 are subject to the least restrictive

    frequency limitation as the required companion code. To calculate the

    amount of time that is payable for prolonged inpatient services, take

    the total unit/floor time and subtract the time of the primary E&M

    service. The following table may be used to calculate billing for

    prolonged inpatient E&M services.

    Time of E&M

    visit code Each additional

    not included First hour 30 minutes

    Less than 30

    minutes Not reported Not reported

    30 74 minutes 99356 Not reported

    75 104 minutes 99356 99357

    105 134 minutes 99356 99357 (quantity of 2)

    135 164 minutes 99356 99357 (quantity of 3)

    165 194 minutes 99356 99357 (quantity of 4)

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    Emergency Department Claims for emergency department E&M services must be

    Services accompanied by an appropriate diagnosis code reflecting the need for the level of E&M services rendered. Inappropriate upcoding is subject to audit.

    No distinction is made between new and established patients in the emergency department. Providers must use CPT-4 codes

    99281 99285 when billing for emergency department services, whether the patient is new or established.

    If a recipient visits the emergency department more than once on the same date of service, the provider should use the recipient’s records from the first visit instead of completing a new evaluation. Claims for E&M services rendered more than once in the emergency department by the same provider, for the same recipient and date of service are reimbursable only if they contain medical justification or an indication from the provider that the recipient came to the emergency department more than once in the same day.

Note: Evaluation and Management (E&M) CPT-4 codes

    99281 99285 are physician service codes and under most

    circumstances, only physicians may submit claims for these

    codes. The treating physician and the emergency department

    services may not submit separate claims using these codes for

    the same recipient and date of service.

    E&M codes 99284 and 99285 are not reimbursable together or more than once to the same provider, for the same recipient and date of service. Instead, providers should use code 99283 to bill for second and subsequent recipient visits on the same date of service.

    E&M: Place of Service/ The CPT-4 and HCPCS codes listed below are restricted to the

    Facility Type Codes following facility type/Place of Service codes:

    Place of

    Facility Type Service Code

    CPT-4 Code Description UB-04 CMS-1500

    99201 99215 Office Services 13, 71, 72, 73, 11, 22, 24, 25,

    74, 75, 76, 79, 53, 65, 71, 72

    83

    99221 99233, Hospital 11, 12 21, 25

    99238, 99239 Services

    99241 99245 Office 13, 14, 24, 33, 11, 12, 22, 23,

    Consultation 34, 44, 54, 64, 24, 25, 53, 55,

    71, 72, 73, 74, 62, 65, 71, 81,

    75, 76, 79, 83, 99

    89

    99251 99255 Initial Inpatient 11, 12, 25, 26, 21, 31, 32, 53,

    Consultation 27, 65, 71, 73, 54, 99

    74, 75, 76, 86

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    The CPT-4 and HCPCS codes listed below are restricted to the following facility type/Place of Service codes (continued):

    Place of

    Facility Type Service Code

    CPT-4 Code Description UB-04 CMS-1500

    99281 99285 Emergency 14* 23

    Department

    Services

    21, 22, 23, 41, 99291 99292 Critical Care 11, 12, 13, 14*

    42 Services

    99341 99350 Home Services 14, 24, 33, 34, 12, 55, 99

    44, 54, 64

    99460, 99462 Newborn Care 11, 12 21

    99477 Neonate 13, 14, 24, 34, 21

    Intensive E&M 44, 54 or 64

    Place of

    Facility Type Service Code

    HCPCS Code Description UB-04 CMS-1500

    X9922 X9970 Adult Subacute 27** 99**

    Care

    X9922 X9970 Pediatric 27** 99**

    Subacute Care

    * Facility type “14” must be billed in conjunction with admit type “1.”

    ** Facility type “27” or Place of Service code “99” must be billed in conjunction with modifier HB to denote adult or HA to denote child.

Refer to the CMS-1500 Completion or UB-04 Claim Form

    Completion Outpatient section of the appropriate Part 2 manual for facility type/Place of Service codes and descriptions. Refer to the end of these sections to see the correspondence between local and national codes.

    Claims for services rendered in an inappropriate facility type/Place of Service will be denied with RAD code 062, “The facility type/Place of Service is not acceptable for this procedure.”

    Note: The codes listed on the previous page cannot be billed with

    facility type code “89” on the UB-04 or Place of Service code

    “81” on the CMS-1500 (independent laboratories). Claims for

    these codes billed with facility type code “89” or Place of

    Service code “81” will be denied.

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    Routine or Standing Services billed to Medi-Cal that are the result of routine or standing Orders Hospitals and orders for admission to a hospital or Nursing Facility Level B (NF-B) Nursing Facilities are not reimbursable when applied indiscriminately to all patients. All Level B (NF-B) patient orders, including standing orders for particular types of cases,

    must be specific to the patient and must represent necessary medical

    care for the diagnosis or treatment of a particular condition. Claims for

    routine orders will be subject to audit for medical necessity and will be

    denied if not justified by the facts relating to the case or if in excess of

    current patient needs.

    The use of routine or standing orders is discouraged by the American

    College of Surgeons, the California Medical Association, the California

    Association of Hospitals and Health Systems, the Joint Commission

    on Accreditation of Healthcare Organizations and the American

    Medical Association.

Board and Care California Code of Regulations, Title 22, Section 51145 defines

    Facility Services and “home” as any place of residence of a recipient other than a hospital,

    Home Visit Codes Nursing Facility Level A (NF-A) or Nursing Facility Level B (NF-B)

    where the recipient is a registered inpatient.

    Since board and care facilities can be considered “home” for Medi-Cal

    patients, home visit CPT-4 codes 99341 99350 may be used to bill

    Medi-Cal for visits to patients in these facilities. Procedure codes

    99304 99316 or 99334 99336, used for visits to board and care

    facilities, are not acceptable and may lead to claim denial. For

    services rendered in a board and care facility, use the “home” facility

    type code “33” on the UB-04 or Place of Service code “12” on the

    CMS-1500 for proper reimbursement.

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    Nursing Facilities: Reimbursement for physician visits to patients in Nursing Facilities Frequency of is limited to once a month in NF Level B (NF-B) facilities, and once Physician Visits every two months in NF Level A facilities (NF-A). Medi-Cal

    regulations mandate visits no less often than once every 30 days for

    the first 90 days following admission to an NF-B and no less often

    than once every 60 days for an NF-A patient. To allow flexibility in

    scheduling NF visits and also to meet medical requirements, Medi-Cal

    reimburses for visits once a month for NF-B patients and 55 60 days

    for NF-A patients.

    Billing Instructions: In those unusual circumstances that require physician visits in excess Additional Visits of the frequencies above, providers must include justification for the

     additional visits in the Remarks field (Box 80)/Reserved for Local Use

     field (Box 19) of the claim or on an attachment included with the claim.

    Hospital Visits Physicians submitting claims to Medi-Cal for hospital visits and

    consultations are reminded that each physician is limited to one initial

    hospital visit (CPT-4 codes 99221 99223) during the recipient’s

    hospital stay.

    The physician must include justification in the Remarks field

    (Box 80)/Reserved for Local Use field (Box 19) of the claim or on an

    attachment for any one of the following services billed for the same

    recipient:

     Hospital visits (CPT-4 codes 99231 99233) exceeding one

    per day

     Hospital visits (CPT-4 codes 99221 99233, 99238, 99239)

    billed on the same day as a consultation (CPT-4 codes

    99251 99255)

     Higher level hospital visit or consultation (CPT-4 codes 99232,

    99233)

Cutback Reimbursement for initial inpatient consultation services billed in

    Reimbursement Rates excess of one per month is cut back as follows:

    Billed Code Cutback Code

    99251 99231

    99252 99231

    99253 99232

    99254 99232

    99255 99232

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    When any of the following procedure codes have been reimbursed

    within a previous period of three years to the same provider, for the

    same recipient, any new patient office visit or home visit codes billed

    by the provider will be reduced to the reimbursement rate of the

    corresponding, established visit procedure codes.

    CPT-4

    Code Range Description

    99211 99215 Established patient; office or other outpatient

    visit

    99221 99223 New or established patient; initial hospital

    care

    99231 99233 subsequent hospital care

    99241 99245 office consultation

    99251 99255 initial inpatient consultation

    99347 99350 Established patient; home visit

    99354 99357 Prolonged physician service with direct (face

    to face) patient contact

    These restrictions do not apply to California Children’s Services (CCS)

    or the Genetically Handicapped Persons Program (GHPP).

Hospital Visit/Discharge A hospital visit (CPT-4 codes 99221 99223 and 99231 99233) is

    Services Rendered on not separately reimbursable when billed with a hospital discharge Same Date of Service service (codes 99238 99239) for the same date of service, for the

    same provider. However, reimbursement will be allowed for both

    services when different rendering providers are billing using the same

    group provider number.

    Outpatient Visits: Medi-Cal reimburses codes 99205 (new patient visit, level five) and Reimbursement Based 99215 (established patient visit, office or other outpatient visit, level on Recipient’s Age five) at different levels based on the patient’s age. Therefore,

    payment reflected on the RAD will vary depending on the age of the

    patient.

Pharmacologic Reimbursement for E&M CPT-4 codes 99201 99215,

    Management: Not 99221 99233, 99238 99350 will be cut back by any amount paid in Separately Reimbursable history for psychiatry code 90862 (pharmacologic management, With Code 90862 including prescription, use, and review of medication with no more

    than minimal medical psychotherapy) to the same provider, for the

    same recipient and date of service.

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