Evaluation management Billing Guide - CPT codes 99201 - 99499

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.



Billing Guide CPT code 99499

Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.


Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service.
Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.

In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

Contractors shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the  provider's first E/M service to the inpatient during the hospital stay. Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M service that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service. Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual.





In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s UPIN/PIN.

In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician  practitioner rate. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose.


• Physicians should us CPT code 99499 with modifier SC V07.31 (medically necessary service).

• Procedure code 99499 SC V07.31 reimburses physicians, ARNPs, and Pas $27.00

• The procedure may be submitted once per claim on the same date of service as other procedures.

• Fluoride varnish may also be applied to a child’s teeth at the time of the Child Health Check-Up visit. It can also be billed with procedure code 99499 SC, as noted above.

• If a child comes to the office for immunizations, the oralevaluation and fluoride varnish can be provided during the same visit and billed using 99499 SC 07.31 in addition to the immunizations service.

• CHIP and Medikids are eligible for this service.


This policy describes reimbursement for Evaluation and Management (E/M) services (99201–99499) reported by nonphysician health care professionals.

EVALUATION AND MANAGEMENT SERVICES

Categorized into different settings depending on where the service is furnished. Examples of settings include:

• Office or other outpatient setting

• Hospital inpatient

• Emergency department (ED)

• Nursing facility (NF) 65

E/M CLAIM PROJECTED ERROR RATE 66 E/M SERVICE ERRORS

• E/M remains the number one Part B CERT error

• E/M services are the top 7 out of 10 services with CERT errors

• The provider types performing E/M services vary greatly

– i.e. Family Practice, Internal Practice, Ophthalmology, General Surgery, Cardiology, Nephrology, Podiatry, Orthopedic Surgery, Psychiatry etc… 67 CPT CODE 99213

• 99.3% of the claim errors related to 99213 included

* Insufficient documentation

• Other E/M codes typically had a 2:1 ratio of errors between insufficient documentation and coding.




WHY ARE ERRORS OCCURRING ?

• Insufficient documentation

• No response to documentation request

• Illegible

• Documentation for wrong patient or date of service submitted

• Documentation does not support level of E/M billed

• Documentation does not adequately describe the service defined by the CPT/HPCS code, or HCPCS modifier billed

• Signature issues - no signature (or no legible signature) and no signature log or attestation submitted

• Does not meet key elements - medical decision making, history or physical exam for billed E/M service level

Reimbursement Guidelines

CPT guidance instructs that E/M (CPT codes 99201-99499) should only be reported by Physicians or specific non-physician practitioners (NPP). In accordance with CMS guidelines, CMS will only pay for E/M services for nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM) provided they are allowed to bill for those services. Physician assistants (PA) are also allowed to provide the service as along asthe physician collaboration and general supervision rules are applied. UnitedHealthcare will not reimburse E/M services (CPT codes 99201-99499) when reported by nonphysician health care professionals not listed above.

The National Correct Coding Initiative Policy Manual gives the following instruction: "Procedures should be reported with the most comprehensive CPT code that describes the services performed." The Current Procedural Terminology (CPT®) book has specific guidelines that give the following instruction: "Select thename of the procedure or service that accurately identifies the service performed." There are a wide variety of CPT and Healthcare Common Procedure Coding System (HCPCS) codes that specifically and accurately identify and describe the services and procedures performed by nonphysician health care professionals.

For evaluation or re-evaluation services, physical and occupational therapists will not be reimbursed for E/M (CPT codes 99201-99499). Consistent with the coding guidelines from the Centers for Medicare and Medicaid Services (CMS), they will only be reimbursed for appropriate use of CPT codes 97001-97004.

Providers are required to use the HCPCS informational modifiers GO (Services delivered under an outpatient occupational therapy plan of care) or GP (Services delivered under an outpatient physical therapy plan of care) when reporting codes 97001-97004 to distinguish procedures provided by different specialists within a multispecialty group.

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