Evaluation and Management Coding Guidelines
The E/M section is divided into categories,
1. Office visit
2. Hospital visit
3. Consultations
Most of the Categories are further divided into two or three subcategories,
1. Office Visit
A. New
B. Established
2. Hospital Visit
A. Initial Hospital care
B. Subsequent Hospital care
C. Hospital Discharge care
The subcategories further classified into levels of E/M services that are identified by specific codes.
This classification is based on place of service, type of service & Patient’s status
NEW AND ESTABLISHED PATIENT:
“New Patient” – Is one who has not received any professional services from the physician/qualified health care professional or another physician of the exact same specialty and subspecialty who belongs to the same group within the past three years.
“Established Patient” – Is one who has received any professional services from the physician/qualified health care professional or another physician of the exact same specialty and subspecialty who belongs to the same group within the past three years.
OFFICE / OUTPATIENT SERVICES:
A.
A. New patient (99202 - 99205)
B. Established patient (99211 - 99215)
The codes are based on MDM (or) Time. The above codes are used to report E/M services provided in the Physician office or in an outpatient (Facility).
Note. CPT 99211 – May not require the presence of a physician or healthcare professional.
HOSPITAL OBSERVATION SERVICES:
The following codes are used to report E/M services provided to patients designated/admitted as “Observation status” in a hospital.
It is not necessary that the patient is located in an observation area designated by the hospital.
A. Initial observation care (99218 - 99220)
B. Subsequent Observation care (99224 - 99226)
C. Discharge care (99217)
D. Admission and Discharge on the same day (99234 - 99236)
Note: Patient admitted to the hospital on a date subsequent to the date of observation status, the hospital admission would be reported (99221-99223).
Don’t report observation discharge (99217) in conjunction with hospital admission (99221-99223).
Office/ED/Nursing facility/Domiciliary/Rest home/Homecare/Preventive services on the same day related to the “observation status” should not be reported separately.
HOSPITAL INPATIENT SERVICES:
The following codes are used to report E/M services provided to patients at Hospital inpatient settings.
A. Initial hospital care (99221 - 99223)
B. Subsequent hospital care (99231 - 99233)
C. Discharge care (99238 & 99239)
D. Admission and Discharge on the same day (99234 - 99236)
ED/Observation/office/nursing facility services provided by the physician in conjunction with hospital admission on the same day are considered as part of the initial hospital care.
Initial encounter by a physician other than admitting physician, ref inpatient consultation codes (99251-99255) For Medicare don’t bill consultation codes, instead bill with Initial hospital admission codes and append “AI” modifier with admitting physician’s service is performed on the first day. Subsequent days would be billed with respective hospital subsequent care CPT codes.
CONSULTATION:
A. OFFICE / OUTPATIENT CONSULTATION (99241 - 99245)
B. INPATIENT CONSULTATION (99251 - 99255)
Watch for “RRR” (Request, Rendered, Report)
1. Service provided at the request of physician / appropriate source (Physician assistant, nurse, PT, OT, Speech therapist, psychologist, social worker, or insurance company)
2. Services rendered by the consultant.
3. Written report back to the requested physician.
Don’t report consultation codes, If the request is made by a patient/or his family.
All subsequent visits by the same consultant must be billed with appropriate E&M codes based on the location (Office / Inpatient)
EMERGENCY DEPARTMENT (ER/ED): (99281 – 99285)
E/M services provided in the Emergency Department (ED is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate attention. The facility must be available 24 hours a day).
“Time” is not a descriptive component for the emergency department levels of E/M.
Other Emergency services: 99288
In directed emergency care, the physician is located in a hospital and in communication with the ambulance outside the hospital.
NURSING FACILITY SERVICES:
The following codes are used to report E/M services provided to patients in nursing facilities. Also to a patient in the psychiatric residential treatment center (A facility for psychiatric care which provides 24 hours therapeutically planned and professionally staffed group living and learning environment)
If psychotherapy is performed along with psychiatric residential E/M service, Should be reported separately.
A. Initial nursing facility care (99304 - 99306)
B. Subsequent nursing facility care (99307 - 99310)
C. Discharge care (99315 & 99316)
If the patient is admitted to the nursing facility from the ED /office on the same day, report only the initial nursing facility care codes.
Hospital discharge / Observation discharge services performed on the same day with Initial nursing facility admission – Should be reported separately.
Other Nursing facility care – 99318
DOMICILIARY, REST HOME, CUSTODIAL CARE SERVICES:
The following codes are used to report E/M services provided to patients in an assisted living facility, group home, custodial care (or) intermediate care facilities.
A. New patient (99324 – 99328)
B. Established patient (99334 – 99337)
DOMICILIARY, REST HOME, HOME CARE PLAN OVERSIGHT SERVICES: (99339 – 99340)
Revision of care plan, new information into the medical treatment plan, within a calendar month 15-29 minutes (99339) or 30 minutes or more (99340) of physician supervision time.
HOME CARE SERVICES:
The following codes are used to report E/M services provided to patients in a residence.
A. New patient (99341 – 99345)
B. Established patient (99347 – 99350)
7. Prolonged services code can be billed with any level of E/M if the level is selected based on key components. If the level of E/M is selected based on “Time”, then only with the highest level of E/M we can bill prolonged services code.
PROLONGED CLINICAL STAFF SERVICES WITH PHYSICIAN SUPERVISION:
CPT 99415 – 99416 used for prolonged clinical staff service beyond the typical face to face time of the E/M service. The physician is present to provide direct supervision of the clinical staff.
This service is reported in addition to the designated E/M services.
Clinical staff prolonged service in office /outpatient. Time need not be continuous on a given date.
Don’t Report if prolonged service is done less than 45 min of total duration on a given date.
CPT 99415 (First hour) and each additional 30 min (99416) don’t report CPT 99416 if less than 15 min beyond the first hour.
STANDBY SERVICES: 99360 (Every 30 minutes)
1. Don’t report If standby service of less than 30 min.
2. Second and subsequent period (full 30 min) of standby service beyond the first 30 min should be reported with appropriate units.
MEDICAL TEAM CONFERENCES:
A. Medical team conference with direct patient/family contact (99366)
B. Medical team conference without direct patient/family contact (99367 & 99368)
Medical team conference is Face-to-face meeting with the minimum of three healthcare professionals from different specialties (Giving care to a particular patient) with or without the presence of the patient/family/caregiver.
No more than one individual from the same specialty may report CPT 99366 – 99368.
Team conference starts at the beginning of the review of an individual patient and ends at the conclusion of the review.
CARE PLAN OVERSIGHT SERVICES: (99374 – 99380)
The complexity and approximate time of the care plan oversight services provided within a 30 days period determine code selection. Only one individual may report services for the given period of time.
Care plan oversight services of a patient in the home, domiciliary, rest home, see CPT 99339, 99340.
PREVENTIVE MEDICINE SERVICES:
A. New Patient (99381 - 99387)
B. Established patient (99391 - 99397)
Preventive medicine evaluation and management of infants, children, adolescents and adults
If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine E/M service and the problem is significant enough to require additional work to perform key components of Problem-oriented E/M service, then appropriate E/M (99201 - 99215) should also be reported along with preventive medicine E/M. Modifier 25 appended with office E/M.
If the abnormality doesn’t require additional work and performance of key components, don’t report office E/M codes along with preventive medicine services.
Preventive medicine examination codes (99381 - 99397) include counseling/risk factor reduction.
COUNSELING RISK FACTOR REDUCTION AND BEHAVIOR CHANGE:
Face-to-face service by a physician for the purpose of promoting health & preventing illness or injury
Risk factor reduction services are used for persons without a specific illness for which counseling is provided.
Distinct problem-oriented E/M may be billed on the same day with modifier 25 with office visit codes.
A. Preventive medicine, Individual counseling (99401 - 99404)
B. Behavior change Intervention, Individual (99406 - 99409)
C. Preventive medicine, group counseling (99411 - 99412)
D. Other preventive medicine services – (99429)
NON FACE TO FACE SERVICES:
A. Telephone services (99441 - 99443)
B. On-Line Medical Evaluation (99421 - 99423)
C. Inter-professional Telephone / Internet Consultations (99446 - 99449)
Telephone services: Non-Face to face E/M service to a patient via Telephone.
1. Telephone calls must be initiated by an established patient or guardian of an established patient.
2. Don’t report, if the patient sees the physician within 24 hrs or next available urgent visit following the Telephone call, Can be considered this as pre-service work to the subsequent E/M.
3. Don’t report, if the Telephone calls related to an E/M performed by that individual within the previous 7 days. This is included service.
4. Don’t report, if the Telephone call is initiated by physician or physician office staff.
5. Don’t consider the time spent with the physician’s office staff on-call or waiting in a call to connect with the physician.
On-Line Medical Evaluation: Non-Face to face E/M service to a patient via internet resources.
1. Physicians response to patient’s inquiry and must be stored.
2. Don’t report, If it is related to the E/M service provided within the previous 7 days.
Interprofessional Telephone / Internet Consultations:
1. Only a consultant should use these codes.
2. Treating physician requests for the opinion / Treatment advice from the expert (Consultant)
3. More than one telephone/internet contact is required, Sum the time and bill with a single code.
4. Don’t report, if the consultant agreed to accept the transfer of care before the telephone/internet.
5. Don’t report, if a consultant has seen the patient within the last 14 days (or) within the next 14 days.
6. Don’t report more than once within a 7 days interval.
7. Don’t report, if the purpose of the call is a transfer of care.
SPECIAL EVALUATION AND MANAGEMENT SERVICES:
A. Basic Life / Disability Evaluation Services (99450)
B. Work-related / Medical disability Evaluation Services (99455 – 99456)
The above codes are used to report evaluation performed to establish baseline information prior to life or disability insurance certificates being issued.
No treatment is done during these visits, If other E/M is performed can be billed additionally.
NEWBORN CARE SERVICES: (99460 – 99463)
1. Services provided to normal newborn (first 28 days from birth)
2. In case of other than normal newborn, report hospital admission/neonatal Intensive care/Critical care codes accordingly.
3. We can bill both normal care visit and illness-related intensive care / critical care services on the same day with modifier 25.
4. We can bill the normal care visit and delivery room attendance service/ resuscitation service on the same day.
5. Newborn circumcision (54150) should be coded additionally if performed.
6. Follow up visits should be coded accordingly (Office visit/Preventive visit CPT’s)
DELIVERY/BIRTHING ROOM ATTENDANCE AND RESUSCITATION SERVICES: (99464 – 99465)
INPATIENT NEONATAL INTENSIVE CARE SERVICES / PEDIATRIC / NEONATAL CRITICAL CARE SERVICES:
A. Pediatric Critical care patient Transport: (99466 – 99486)
B. Inpatient Neonatal and Pediatric Critical care: (99468 – 99476)
Pediatric Critical care patient Transport:
1. CPT 99466, 99467 – Physician Direct face to face interfacility transport of critically ill patient 24 months of age or younger.
2. CPT 99485, 99486 – Physician Non-face-to-face supervision of interfacility transport of critically ill patient 24 months of age or younger.
3. Don’t report CPT 99466 (30 to 74 minutes) if less than 30 min.
4. Don’t report CPT 99485 (16 to 45 minutes) if less than 15 min.
5. Included and Excluded services list, please refer to the CPT book for details.
Inpatient Neonatal and Pediatric Critical care:
1. CPT 99468, 99469 – Critically ill inpatient service for 28 days of age or younger.
2. CPT 99468 (Initial) should be used only once per hospital stay on initial admission day.
3. If readmitted for neonatal critical care unit during the same hospital stay, use 99469 (subsequent) for the first day of readmission to critical care.
4. CPT 99471 – 99476: critically ill inpatient service for 29 days of age to 5 yrs of age.
5. CPT 99471, 99475 (Initial) should be used only once per hospital stay on initial admission day.
6. If readmitted for pediatric critical care unit during the same hospital stay, Use 99472/99476 (subsequent) for the first day of readmission to critical care.
7. Included services are listed under CPT 99291 and also refer CPT book for complete details.
8. Critically ill outpatient service for any age group – CPT 99291, 99292.
9. Critically ill child 6 yrs of age or older – use CPT 99291, 99292
10. If the same individual provides Critical care services for neonate/pediatric patient less than 6 yrs of age in both outpatient and inpatient setting on the same day, code only Inpatient codes.
11. If the same individual provides Critical care services and hospital care/intensive care, only the Critical care services code (99468, 99471, and 99475) is reported.
INITIAL / CONTINUING INTENSIVE CARE SERVICES: (99477 – 99480)
1. CPT 99477 (Initial day) intensive care for inpatient who is not critically ill.
2. CPT 99478 – 99480 (subsequent day) intensive care codes based on the weight of the baby.
3. If readmitted to the intensive care unit during the same hospital stay, use 99478 - 99480 (subsequent) for the first day of readmission to the intensive care unit.
4. Included services are listed under Neonatal and pediatric critical care services section, Ref Book
5. If the patient is transferred to a lower level of care, then report appropriate inpatient subsequent codes (99231- 99233) or normal newborn care (99460, 99462) for transferring the individual.
6. If the patient is transferred to a lower level of care on the same day. Report only 99477.
7. For the subsequent care of the sick newborn younger than 28 days but more than 5000 grams who doesn’t require intensive/critical care services, use code 99231 – 99233.
COGNITIVE ASSESSMENT AND CARE PLAN SERVICES: (99483)
1. Services to cognitive impairment patients.
2. Don’t report if any of the required elements (Listed under CPT code) are not performed.
3. A single physician should not report CPT 99483 more than once every 180 days.
CARE MANAGEMENT SERVICES:
Management and support services provided by clinical staff, under the direction of the physician to a patient residing at home/domiciliary/rest home / assisted living facility.
The physician provides/oversees the management as needed.
Only count the time of one clinical staff member if two or more staff meeting the patient.
Included services please refer the CPT manual for more details.
A. Chronic care management Services – (99490)
B. Complex Chronic care management Services – (99487 & 99489)
The above CPT’s are reported only once per calendar month by a single physician.
Chronic care management Services:
1. Patient with two or more chronic health conditions that are expected to last at least 12 months or until death.
2. During the calendar month at least 20 minutes of clinical staff time spent in care management activities – Report CPT 99490.
Complex Chronic care management Services:
1. Complex Chronic care management Services (99487 & 99489) – Patient with two or more chronic health conditions that are expected to last at least 12 months or until death. Requires revision of a comprehensive care plan.
2. At least 60 minutes of clinical staff time spent under the direction of a physician.
3. Don’t report, Care plan is unchanged/minimal changes (Eg: medication change)
4. Don’t report, CPT 99487, 99489, 99490 for any post-discharge care management services for any days within 30 days of discharge.
PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT SERVICES: (99492 - 99494)
1. Psychiatric collaborative care services are provided under the direction of a treating physician during a calendar month. These services are reported by the treating physician.
2. Don’t report CPT 99492 and 99493 in the same calendar month.
TRANSITIONAL CARE MANAGEMENT SERVICES (TCM): (99495 – 99496)
1. TCM commences upon the date of discharge and continues for the next 29 days.
2. Transitional care from a Hospital inpatient/observation/skilled nursing facility to the patient community settings (Home/domiciliary/rest home/assisted living)
3. TCM comprised of one face-to-face within the specified timeframe in addition with non-face-to-face services performed by physician or clinical staff under his direction.
4. Only one individual may report these services and only once per patient within 30 days of discharge.
5. The same individual should not report TCM service provided in the postoperative period.
6. TCM requires interactive contact with the patient /caregiver within two business days of discharge. Either direct, telephone, electronic means.
7. The first face to face visit is part of TCM don’t report separately. Additional subsequent face to face visits can be billed separately.
8. CPT 99495 - MDM of moderate complexity face to face visit occur within 14 days from discharge.
9. CPT 99496 – MDM of high complexity face to face visit occur within 7 days from discharge.
10. MDM of high complexity but face to face visit occur after 8th to 14 days – Report CPT 99495.
ADVANCE CARE PLANNING: (99497 & 99498)
1. Face to face service with physician and patient/family member/surrogate in counseling and discussing advance directives.
2. CPT 99497, 99498 – No active management of the problems is undertaken during the visit.
3. If these services are performed on the same day with other E/M services, bill separately.
GENERAL BEHAVIORAL HEALTH INTEGRATION CARE MANAGEMENT: (99484)
1. This service is reported by the supervising physician; Services are performed by the clinical staff for patients with behavioral health condition require care management services of 20 minutes or more in a calendar month.
2. General behavioral health integration care management and Psychiatric collaborative care management may not be reported by the same individual in the same month.
3. General behavioral health integration care management and Chronic care management services may be reported by the same individual in the same month if distinct.
OTHER E/M SERVICES: (99499) - Unlisted E/M Service CPT
___________________________________________________________________
________________________________________________
Ref: CPT manual (Copyrights by AMA)
____________________________________