ModifiedIndiana Department of InsurancePolicy PROMOD00026

Evaluation and Management Services

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This policy governs coding, reimbursement, documentation, and service limitations for evaluation and management services provided to Indiana Health Coverage Programs members under the fee-for-service delivery system. Managed care providers must follow their managed care entity's provider manual or contact the entity.

Policy Summary

PayerIndiana Department of Insurance

PolicyEvaluation and Management Services

Policy CodePolicy PROMOD00026

Change TypeModified — Version 8.0

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for office visits exceeding 30 combined visits per member per calendar year.

SourceLink

POLICY UPDATE CHANGES

Version 8.0 edited policy text as needed for clarity.

Version 8.0 added Indiana PathWays for Aging to the managed care applicability note.

Version 8.0 updated the Components of Evaluation and Management Code Selection section.

Version 8.0 updated the Nursing Facility Visits section.

Version 8.0 added the Prolonged Nursing Facility E/M Services section.

Version 8.0 updated Table 3 for hospital inpatient and observation E/M services.

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ModifiedIndiana Department of InsurancePolicy PROMOD00026

Evaluation and Management Services

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Sign up for Indiana Department of Insurance Policy PROMOD00026 alerts

Get alerted when Policy PROMOD00026 changes without checking for updates manually.

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Policy Summary

PayerIndiana Department of Insurance

PolicyEvaluation and Management Services

Policy CodePolicy PROMOD00026

Change TypeModified — Version 8.0

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for office visits exceeding 30 combined visits per member per calendar year.

SourceLink

POLICY UPDATE CHANGES

Version 8.0 edited policy text as needed for clarity.

Version 8.0 added Indiana PathWays for Aging to the managed care applicability note.

Version 8.0 updated the Components of Evaluation and Management Code Selection section.

Version 8.0 updated the Nursing Facility Visits section.

Version 8.0 added the Prolonged Nursing Facility E/M Services section.

Version 8.0 updated Table 3 for hospital inpatient and observation E/M services.

30Maximum office visits without prior authorization

1 per 3 yearsNew patient office visit limit

1 per 27 daysNursing facility visit limit without supporting documentation

15 minutesAdditional time required for applicable prolonged E/M add-on codes

4Noncovered consultation code families

1 per admissionInitial inpatient consultation limit

Coverage and Reimbursement Criteria

Office Visit Annual Limit and Prior Authorization

Office visits are reimbursable for a maximum of 30 combined visits per member per calendar year without prior authorization (PA). Additional visits require PA and must be medically necessary.

ALL of the following

The services are office or other outpatient evaluation and management (E/M) or comprehensive preventive medicine visits represented by CPT codes 99202–99205, 99211–99215, 99381–99387, or 99391–99397.
The combined number of applicable visits for the member during the calendar year does not exceed 30, unless PA has been obtained.
Each visit is appropriate to the diagnosis and treatment provided and is properly coded.

Additional office visits beyond the 30-visit combined annual limit require PA and must be medically necessary.

Claims for units in excess of 30 without PA will be denied with EOB code 6012: reimbursement is limited to 30 medical services per member per rolling calendar year unless PA has been obtained.

New Patient Office Visit Limitation

New patient office visits are limited by member, provider, and specialty/subspecialty group.

ALL of the following

The service is a new patient office or other outpatient visit or an initial comprehensive preventive medicine visit represented by CPT codes 99202–99205 or 99381–99387.
The member has not received any professional services from the billing provider or from another provider of the same specialty and subspecialty within the same group practice during the preceding three years.
No more than one such new patient visit is billed for the member by the provider within the preceding three years.

Claims exceeding the new patient visit frequency limit will be denied with EOB code 6006: new patient visits are limited to one per member, per provider, within the last three years.

The limitation is applied by member, provider, and the same specialty/subspecialty group practice.

Nursing Facility Visit Limitation

For members residing in nursing facilities, facility E/M reimbursement is limited to one applicable visit every 27 days unless the record supports the need for additional visits.

ALL of the following

The service is an applicable nursing facility or assisted living E/M visit: CPT 99304–99306, 99307–99310, or 99341, 99342, 99344, 99345.
No more than one applicable E/M visit is billed during the same 27-day period, unless additional visits are supported by sufficient medical-record documentation.

Additional visits during the same 27-day period are supported by documentation such as treatment of an emergent, urgent, or acute condition or symptom with a new diagnosis code.

Documentation must be retained on file for postpayment review.

Prolonged E/M Service Criteria

Prolonged E/M add-on codes are reportable only when the primary visit code is selected primarily by total time and the applicable highest-level service time has been exceeded by at least 15 minutes.

ALL of the following

ONE of the following applicable primary services
- Office or other outpatient E/M: total time exceeds the time required for CPT 99205 or 99215 by at least 15 minutes; report G2212 or 99417.
- Nursing facility E/M: total time exceeds the time required for CPT 99306 or 99310 by at least 15 minutes; report 99418.
- Inpatient or observation E/M: total time exceeds the time required for CPT 99223, 99233, or 99236 by at least 15 minutes; report 99418.
The applicable add-on code is listed separately in addition to the primary E/M code.

Hospital Inpatient, Observation, and Discharge Billing

Hospital inpatient and observation E/M services, including related discharge and critical care services, must be reported as professional services and selected according to the patient’s status and service date.

ALL of the following

Physician and other professional E/M services rendered during a hospital stay are submitted on a professional claim: CMS-1500, IHCP Provider Healthcare Portal professional claim, or 837P electronic transaction.
Observation is not an inpatient service; professional claims for observation services use an outpatient place-of-service (POS) code.
Use the applicable service code
- CPT 99221–99223: initial hospital care, per day, for the first day of inpatient or observation care when the patient is discharged on a different date.
- CPT 99231–99233: subsequent hospital care, per day.

Hospital Discharge Service Criteria

Select the hospital discharge code based on whether discharge occurs on the admission/observation-initiation date and document the applicable time.

ALL of the following

ONE of the following
- Discharge occurs on a date different from the initial inpatient admission or initiation of observation status; report CPT 99238 or 99239 based on the amount of time spent discharging the patient.
- Discharge occurs on the same date as inpatient admission or initiation of observation status; report CPT 99234–99236.
The amount of time supporting CPT 99238 or 99239 is documented in the medical record when one of those codes is billed.

If the patient is discharged from the hospital and admitted to a nursing facility on the same date by the same provider, report the hospital discharge service separately from the nursing facility admission.

Consultation Coverage and Reporting Criteria

A consultation is covered as a service when the consultation requirements are met, but IHCP does not cover the consultation-specific CPT codes. Report the E/M code that reflects the site and complexity of the service.

ALL of the following consultation requirements

Another physician or other appropriate healthcare professional requests the consulting physician’s medical opinion regarding a specific member’s condition.
The requesting and consulting professionals collaborate regarding the member’s care.
The consulting physician examines the patient unless the applicable standard of care does not require a physical examination.
The consulting physician may initiate diagnostic or therapeutic services.
The patient is not self-referred and the service is not solely non-physician-referred; self-referred or non-physician-referred evaluation is not a consultation under 405 IAC 5-8-3(a).

Inpatient and Confirmatory Consultation Criteria

Initial and follow-up inpatient consultations are reimbursable only under the applicable frequency, request, and participation conditions. A confirmatory consultation may be billed only when specifically requested for a second or third medical opinion.

Initial inpatient consultation

The consultation is performed for a member during an inpatient hospital or nursing facility admission.
No more than one initial consultation is reimbursed per consultant, per member, per inpatient hospital or nursing facility admission.

Follow-up inpatient consultation is reimbursable when ONE of the following applies

Additional visits are needed to complete the initial consultation.
The attending physician requests subsequent consultative visits to monitor progress, recommend management modifications, or advise on a new plan of care in response to changes in the member’s status.

Covered and Noncovered Codes

Covered Office Visit CPT CodesCPTCovered

99202-99205	Office or other outpatient visit for the evaluation and management of a new patient
99211-99215	Office or other outpatient visit for the evaluation and management of an established patient
99381-99387	Initial comprehensive preventive medicine visit for the evaluation and management of a new patient
99391-99397	Periodic comprehensive preventive medicine visit for the reevaluation and management of an established patient

Covered Prolonged Office or Other Outpatient E/M CodesHCPCSCovered

G2212	Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes
99417	Prolonged outpatient service, each 15 minutes of total time beyond required time of primary service

Noncovered CodeHCPCSNot Covered

99483

Not covered by IHCP

Covered Modifiers for Separately Reportable E/M with SurgeryModifierCovered

25	Significant, separately identifiable E/M service by the same physician on the same day as a procedure
57	E/M service resulting in the initial decision to perform surgery

Covered Nursing Facility and Assisted Living Visit CodesCPTCovered

99304-99306	Initial nursing facility visit
99307-99310	Subsequent nursing facility visit
99341	New patient assisted living visit
99342	New patient assisted living visit
99344	New patient assisted living visit
99345	New patient assisted living visit

Covered Prolonged Nursing Facility E/M CodeCPTCovered

99418

Prolonged inpatient or observation service, each 15 minutes of total time beyond required time of primary service

Covered Emergency Department CPT CodesCPTCovered

99281-99285

Emergency department visit codes reflecting the appropriate level of screening examination

Covered Hospital Inpatient and Observation Care CPT CodesCPTCovered

99221-99223	Initial hospital care per day, including the first day of inpatient or observation care
99231-99233	Subsequent hospital care per day
99234-99236	Initial hospital or observation care with same-day admission and discharge
99418	Prolonged inpatient or observation E/M service, each additional 15 minutes beyond the required time of 99223, 99233, or 99236

Covered Hospital Discharge and Critical Care CPT CodesCPTCovered

99238-99239	Hospital inpatient discharge day management when discharge occurs on a date different from admission
99234-99236	Discharge service when admission and discharge occur on the same date
99291-99292	Critical care E/M for critically ill or critically injured patients

Noncovered Provider Specialty Exclusion CPT CodesCPTNot Covered

99204	Detailed or comprehensive office visit not eligible for reimbursement for podiatrists and chiropractors
99205	Detailed or comprehensive office visit not eligible for reimbursement for podiatrists and chiropractors
99214	Detailed or comprehensive office visit not eligible for reimbursement for podiatrists and chiropractors
99215	Detailed or comprehensive office visit not eligible for reimbursement for podiatrists and chiropractors

Covered Different-Day Hospital Discharge ServicesCPTCovered

99238	Hospital discharge day management, used when discharge occurs on a different date from admission or observation initiation
99239	Hospital discharge day management, used when discharge occurs on a different date from admission or observation initiation

Covered Same-Day Hospital or Observation Discharge ServicesCPTCovered

99234	Hospital or observation discharge service when discharge is on the same date as admission or observation initiation
99235	Hospital or observation discharge service when discharge is on the same date as admission or observation initiation
99236	Hospital or observation discharge service when discharge is on the same date as admission or observation initiation

Covered Critical Care ServicesCPTCovered

99291	Physician critical care services
99292	Physician critical care services

Noncovered Office or Outpatient Consultation CPT CodesCPTNot Covered

99242-99245

Office or outpatient consultation services; noncovered

Covered E/M Alternatives for Consultation VisitsCPTCovered

99202-99205	New patient office and other outpatient visits that may be used for covered consultation visits
99211-99215	Established patient office and other outpatient visits that may be used for covered consultation visits
99221-99223	Initial hospital care visits that may be used for covered consultation visits
99231-99233	Subsequent hospital care visits that may be used for covered consultation visits

Office visits without prior authorization

Annual limitMaximum 30 combined office visits per member per calendar year without prior authorization

Additional visitsAdditional office visits require prior authorization and must be medically necessary

Excess-claim dispositionClaims for units in excess of 30 without prior authorization are denied with EOB code 6012

New patient visit frequency

Billing and Documentation Actions

Prior Authorization

Prior Authorization Required After 30 Office Visits

Obtain prior authorization before billing office or other outpatient E/M visits that exceed the combined annual limit of 30 visits per member. Additional visits must be medically necessary; claims exceeding 30 without prior authorization may be denied under EOB code 6012.

Applies to CPT codes 99202–99205, 99211–99215, 99381–99387, and 99391–99397.
The 30-visit limit applies to the combined total of all applicable codes per calendar year.

Denial Risk

Limit New Patient Visit Frequency

Do not bill more than one new patient office or preventive medicine visit per member, per provider, within the preceding three years. Claims exceeding this limit may be denied under EOB code 6006.

Applies to CPT codes 99202–99205 and 99381–99387.

Key Policy Definitions

Evaluation and management services

PurposeEvaluation and management services are used to assess a member’s health or condition and provide direction for the member’s healthcare

Required componentE/M services must include obtaining a medical and social history, conducting a physical examination, and making a medical decision

ScopeThe module provides information on medical E/M services

E/M code selection

Primary selection methodsFor most E/M categories, the level is determined by medical decision making or by total time spent on the date of the encounter

Time activitiesTotal time may include preparing for the visit, obtaining or reviewing history, examining or evaluating the patient, counseling, ordering services, and documenting clinical information

Policy Summary

PayerIndiana Department of Insurance

PolicyEvaluation and Management Services

Policy CodePolicy PROMOD00026

Change TypeModified — Version 8.0

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for office visits exceeding 30 combined visits per member per calendar year.

SourceLink

On This Page

Medical necessity for the prolonged service is documented in the medical record.

The primary visit code was not selected primarily using the medical decision-making (MDM) matrix.

G2212 is reported in 15-minute units and may not be reported for any time unit of less than 15 minutes.

G2212 may be reported with 99205, 99215, or 99483; 99483 is not covered by IHCP. Do not report G2212 on the same date as 99358, 99359, 99415, or 99416.

Providers may not bill both G2212 and 99417 for the same visit; IHCP reimburses these procedure codes at the same rate.

CPT 99234–99236: same-day admission and discharge for observation or inpatient status.

CPT 99418: prolonged inpatient or observation service, each additional 15 minutes beyond the required time of CPT 99223, 99233, or 99236, when the service is selected primarily by time and medical necessity is documented.

CPT 99238–99239: hospital discharge day management when discharge occurs on a date different from the initial inpatient admission or observation initiation.

CPT 99291–99292: critical care E/M services for a critically ill or critically injured patient.

Use 99238 or 99239 when discharge is on a different date from admission or observation initiation; use 99234–99236 when admission or observation initiation and discharge occur on the same date.

Do not report consultation CPT codes 99242–99245 (office/outpatient consultation) or 99252–99255 (hospital/inpatient consultation); these codes are noncovered.

Report the applicable E/M code for the location and complexity of the service, including 99202–99205 or 99211–99215 for office/outpatient visits and 99221–99223 or 99231–99233 for hospital care.

The consulting physician initiated treatment at the initial consultation and continues to participate in the member’s management; report subsequent hospital care codes instead of consultation codes.

Confirmatory consultation

The consultation is specifically requested by another physician or an IHCP contractor as part of the prior authorization process.
The consultation is performed by a physician for a specific member to render a second or third medical opinion.

Frequency limitOne new patient office visit per member, per provider, within the past three years

New patient codesThe limit applies to CPT codes 99202-99205 and 99381-99387

Excess-claim dispositionClaims in excess of the limit are denied with EOB code 6006

Nursing facility visit frequency

Frequency limitOne nursing facility E/M visit per 27 days without documentation supporting additional visits

Supporting documentationDocumentation must justify additional visits, such as treatment of emergent, urgent, or acute conditions or symptoms with a new diagnosis code

Record retentionDocumentation must be kept on file for postpayment review

Prolonged service threshold

Time thresholdMore than 15 minutes beyond the required time of the highest-level primary service

Code-selection requirementThe primary visit code must be selected primarily using total time

Documentation requirementMedical necessity must be documented in the medical record

Initial inpatient consultation frequency

Frequency limitOne initial inpatient consultation per consultant, per member, per inpatient hospital or nursing facility admission

Follow-up consultationsFollow-up inpatient consultations are reimbursable when needed to complete the initial consultation or requested by the attending physician

Subsequent care codingWhen the consulting physician initiates treatment at the initial consultation and participates thereafter in the member’s management, codes for subsequent hospital care should be used

A new patient has not received professional services from the provider or another provider of the same specialty and subspecialty in the same group practice.

Unsupported block type: documentation

Documentation Required

Document and Code Prolonged Services

Use prolonged-service add-on codes only when the primary E/M code is selected primarily by time and the total time of the highest-level service has been exceeded by at least 15 minutes. Document medical necessity and the total time supporting the prolonged service.

For office or outpatient services, report G2212 or 99417 separately with 99205 or 99215; do not report both for the same visit, and do not use G2212 for fewer than 15 minutes.
For nursing facility services, report 99418 separately with 99306 or 99310.
For inpatient or observation services, report 99418 separately with 99223, 99233, or 99236.
Do not use prolonged-service add-on codes when the visit code is selected primarily using the MDM matrix.

Documentation Required

Document a Separately Identifiable E/M Service

When surgery is performed during an office visit, report the E/M service separately only when it is supported by a qualifying circumstance and is distinct from the surgical service. The medical record must substantiate the separate E/M service.

Use modifier 25 for a significant, separately identifiable E/M service on the same day as a procedure.
Use modifier 57 when the E/M service resulted in the initial decision to perform surgery.
Qualifying circumstances include a new patient evaluation, the decision to perform surgery made during the visit, or evaluation of a separate clinical condition.

Billing Rule

Select the Discharge Code by Admission and Discharge Date

Select the hospital discharge code based on the relationship between the admission and discharge dates and the time spent discharging the patient. Use 99238 or 99239 when discharge is on a different date from admission or initiation of observation, and use 99234–99236 when admission and discharge occur on the same date.

Apply these rules to discharge from either inpatient or observation care.
Document the amount of discharge-service time in the medical record to substantiate the billed code.

Documentation Required

Document Hospital Discharge-Service Time

Record the time spent discharging the patient in the medical record and select the discharge code that corresponds to that time. This documentation must substantiate the billed discharge service.

For different-day discharge services, use 99238 or 99239, depending on the amount of time spent.
For same-day admission and discharge, use 99234–99236.

Billing Rule

Report Hospital Discharge and Nursing Facility Admission Separately

When a patient is discharged from a hospital and admitted to a nursing facility on the same date by the same provider, report the hospital discharge service separately from the nursing facility admission. Select the discharge code according to whether the patient was admitted and discharged on the same date or on different dates.

Use 99238 or 99239 when discharge occurs on a different date from the initial admission or initiation of observation.
Use 99234–99236 when admission or initiation of observation and discharge occur on the same date.

Billing Rule

Use Applicable E/M Codes Instead of Consultation Codes

Do not bill the noncovered consultation CPT codes. Report the service with the applicable E/M code that reflects where the visit occurred and the complexity of the service performed.

Noncovered consultation codes include 99242–99245 for office or outpatient consultations and 99252–99255 for hospital or inpatient consultations.
Applicable E/M codes may include 99202–99205, 99211–99215, 99221–99223, and 99231–99233.

Documentation Required

Meet Consultation Requirements

Meet all applicable consultation requirements before reporting a service as a consultation: the consulting physician must provide an opinion requested by another physician or appropriate health care professional, collaborate with the requester, and examine the patient unless the applicable standard of care does not require a physical examination. A self-referred or non-physician-referred patient is not considered a consultation.

Document the request and collaboration between the requesting and consulting clinicians.
The consulting physician may initiate diagnostic or therapeutic services after the consultation.

Billing Rule

Apply the Initial Inpatient Consultation Limit

Limit initial inpatient consultations to one per consultant, per member, per inpatient hospital or nursing facility admission.

Follow-up inpatient consultations may be billed when needed to complete the initial consultation or when requested by the attending physician.
Use subsequent hospital care codes when the consulting physician initiates treatment at the initial consultation and continues participating in the member’s management.

Prior Authorization

Bill Confirmatory Consultations Only When Requested

Bill a confirmatory consultation only when another physician or an IHCP contractor specifically requests a second or third medical opinion for a particular member, including when the consultation is required to substantiate medical necessity during prior authorization.

Document the specific request and the purpose of the confirmatory consultation.

Time-code requirementWhen using total time, the time listed in the descriptor must meet or exceed the time listed for the code billed

Observation care

Inpatient statusObservation care is not considered an inpatient service

Claim treatmentProfessional claims for observation E/M services should use an outpatient place-of-service code

Professional billingHospital E/M services must be submitted on a professional claim, including a CMS-1500, IHCP Provider Healthcare Portal professional claim, or 837P transaction

New patient

DefinitionA new patient is one who has not received professional services from the provider or another provider of the same specialty and subspecialty in the same group practice

Professional-service historyThe determination depends on whether the member previously received professional services from the provider or another provider in the applicable specialty and subspecialty

Related frequency ruleNew patient office visits are limited to one per member, per provider, within the past three years

Consultation

DefinitionA consultation is a service provided by a physician whose medical opinion about a member’s specific condition is requested by another physician or other appropriate healthcare professional

CollaborationA consultation requires collaboration between the requesting and consulting physician

ExaminationThe consulting physician must examine the patient unless the applicable standard of care does not require a physical examination

Follow-up inpatient consultation

DefinitionA follow-up consultative visit is needed to complete the initial consultation or is requested by the attending physician

Permitted purposesFollow-up visits may monitor progress, recommend management modifications, or advise on a new plan of care in response to changes in the patient’s status

Alternative codingIf the inpatient consulting physician initiated treatment at the initial consultation and participates thereafter in the patient’s management, codes for subsequent hospital care should be used

Confirmatory consultation

DefinitionA confirmatory consultation is requested by another physician or an IHCP contractor to render a second or third medical opinion for a specific member

Request requirementThe consultation may be billed only when it is specifically requested by another physician or IHCP contractor

PurposeA confirmatory consultation may substantiate medical necessity as part of the prior authorization process