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Evaluation and management services


Evaluation and management (E/M) services refer to visits and consultations furnished by physicians. E/M CPT codes is a category of billing for physician that provide a way to classify the extent of a physician’s work, focuses on understanding the patient's problems and analyze and report those physician services.

1. New Patient CPT 99201 - 99205


A new patient is one who has not received any professional services 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 member received within three years will be paid at the level of the comparable established patient procedure.

2. Established Patient CPT 99211 - 99215


An established patient is one who has received professional services from the provider with the past three years.

E & M Services 'Not Separately Reimbursable' if the following CPT-4 codes for E & M services billed by the same provider, for the same recipient and for the same date of service. In such case, 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 (CPT 99201 – 99205) and another new patient, office or other outpatient visit (CPT 99201 – 99205)

• New or established patient (CPT 99201 - 99215) and initial hospital care (99221 – 99223) and subsequent hospital care (99231 – 99233).

• New or established patient (CPT 99201 - 99215) and initial inpatient consultation (99251 – 99255).

• Initial hospital care and or subsequent hospital care (99221 - 99233) and Initial inpatient consultation (99251 - 99255)

• The preventive medicine service, new or established patient visit (99381 – 99397) and a new or established patient, office or other outpatient visit (99201 – 99215) billed by the same provider, for the same patient, for the same date of service, without modifier 25 on the office visit code, will be reimbursed only for the higher paying of the two codes.

Emergency Department Services

Providers must use CPT-4 codes 99281 – 99285 when billing for emergency department services, whether the patient is new or established in the Place of service 23 in CMS-1500.

Observation visits


Observation Status is defined as services that are reasonable and necessary to evaluate an outpatient’s condition to determine the need for admission.

Observation codes:

• CPT 99218, 99219, 99220 (If the patient stay is 1-7 hrs and discharged in same calendar day or the patient has stayed past midnight)

• CPT 99234, 99235, 99236 (minimum patient stay of 8 hours within same calendar day and patient is discharged before midnight). It includes both observation and discharge services

• CPT 99211-99215 (Day 2 in observation is coded as outpatient E&M office visit (99211 – 99215).
Effective for dates of services on and after Jan 1, 2011 CPT codes 99224-99226 should be reported for subsequent Observation care.

 
• CPT 99217 (Observation discharge)

E / M CPT codes and applicable place of services reported in CMS 1500 claim form
 

1. Office visits CPT 99201- 99215 - POS 11, 22, 24, 25, 65, 71, 72

2. Hospital visits CPT 99221 - 99233 and CPT 99238 - 99239 - POS 21, 25

3. Office consultation CPT 99241 - 99245 - POS 11, 12, 22, 23, 24, 25, 53, 55, 62, 65, 71, 81, 99

4. Inpatient consultation CPT 99251 - 99255 - POS 21, 31, 32, 53, 54, 99

5. Emergency Room services CPT 99281 - 99285 - POS 23

6. Critical care services CPT 99291 - 99292 - POS 21, 22, 23

7. Home services CPT 99341 - 99350 - POS 12, 55, 99

8. New born care CPT 99460 - 99463 - POS 21


For detailed list of Place of services please visit https://www.cms.gov/MedHCPCSGenInfo/Downloads/Place_of_Service.pdf

 

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