CurrentCentenePolicy CC.PP.071

E&M Services Billed with Treatment Room Revenue Codes

This Centene payment policy governs reimbursement for facility evaluation and management (E/M) charges billed in conjunction with treatment room revenue codes for outpatient/hospital campus services (Type of Bill 130x). It affects providers submitting hospital outpatient claims to Centene-operated health plans.

Policy Summary

PayerCentene

PolicyE&M Services Billed with Treatment Room Revenue Codes

Policy CodePolicy CC.PP.071

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not bill facility E/M charges with treatment room revenue codes unless the E/M is directly related to a same-day procedure; such lines will be evaluated and may be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

760, 761, 769Revenue codes evaluated

99202-99499E/M codes referenced

130xApplies to bill type

DeniedDenial consequence

Reimbursement and Billing Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement and billing rules

Covered/reimbursable determinations for facility E/M charges billed with treatment room revenue codes:

Claims will be evaluated by the health plan's code editing software when a treatment room revenue code is billed in conjunction with an Evaluation and Management (E/M) service.

Reimbursement allowed when ALL of the following are met:

The facility treatment room service is directly related to a procedure provided on the same day the treatment is rendered.
The reported service represents a specific procedure performed in the treatment room (not an office-based E/M).

Facility E/M charges billed in conjunction with a treatment room revenue code that do not represent a specific procedure performed in the treatment room will not be reimbursed; billing treatment room revenue codes for office-based E/M services is incorrect coding and will not be reimbursed.

Any service line reported incorrectly after code editing review will be denied for reimbursement.

Revenue, E/M and Revenue Code Edits

Revenue codes (UB revenue)Revenue

0760	Specialty Services General (revenue code)
0761	Treatment Room (revenue code)
0769	Other Specialty Services (revenue code)

CPT E/M codesCPT

99202-99499

Evaluation and Management Services (CPT range)

HCPCS codesHCPCS

G0380-G0384	Procedures and Professional Services (HCPCS)
G0463	Procedures and Professional Services (HCPCS)
G2212	Procedures and Professional Services (HCPCS)

inv-03: Revenue code edit evaluation

ScopeRevenue codes 760, 761, 769 billed with Evaluation and Management (E/M) services will be evaluated by the plan's code editing software.

ConsequenceAny service line reported incorrectly will be denied for reimbursement.

Applicable codesRevenue codes: 0760, 0761, 0769; E/M: CPT range 99202-99499 and related HCPCS (G0380-G0384, G0463, G2212).

ContextThis evaluation applies when treatment room revenue codes are billed in conjunction with facility E/M charges on hospital outpatient claims (Type of Bill 130x).

Billing, Prior Review and Provider Requirements

Billing Rule

Prior review and billing rules for treatment room revenue codes

Claims billed with revenue codes 760, 761, or 769 in conjunction with Evaluation and Management (E/M) services will be evaluated by the health plan's code editing software; any service line reported incorrectly will be denied. Facility E/M charges billed with treatment room revenue codes are not reimbursed because they do not represent a specific procedure performed in a treatment room, except when the facility treatment room service is directly related to a procedure provided on the same day.

Code editing software will review claims with revenue codes 760, 761, 769 when submitted with E/M services.
Incorrectly reported service lines will be denied for reimbursement.
Facility treatment room revenue codes are reimbursable only if directly related to a same-day procedure.

Key Definitions

inv-05: Revenue Code

DefinitionA revenue code is a four-digit number on hospital bills used to indicate where the patient was when they received treatment or the type of item or service provided.

PurposeRevenue codes inform insurers how to adjudicate and reimburse institutional services.

UsageUsed on UB-04 hospital bill forms and required to be accompanied by a valid procedure code for acceptance.

inv-06: Evaluation and Management Service

DefinitionEvaluation and Management (E/M) services are services reported by physician and non-physician practitioners across multiple settings including office, outpatient, hospital inpatient, consultations, emergency department, nursing facility, domiciliary and home services.

CodingE/M services are reported using CPT codes (example range referenced in this policy: 99202-99499).

ContextThis policy evaluates E/M services when billed in conjunction with treatment room revenue codes on hospital outpatient claims.

inv-07: Minor Procedure

DefinitionMinor procedures are minimally invasive surgical procedures performed over a brief period of time, sometimes laparoscopically or arthroscopically with small incisions.

ExamplesBiopsies, removal of warts or lesions, repairs of small wounds, removal of hemorrhoids or abscesses.

SettingOften performed in a treatment room on hospital premises where the patient is registered through the hospital outpatient business office.

inv-08: UB-04

DefinitionUB-04 forms are used by hospitals and other institutional providers to bill for facility services.

RequirementA valid procedure code must accompany a revenue code on the UB-04 for the claim to be accepted by the insurance provider.

PurposeUB-04 conveys institutional billing details including revenue codes that affect reimbursement adjudication.