Physician Services Coverage Policy

Coverage Summary

Overview: This policy addresses coverage, billing, limitations, and documentation requirements for physician services including routine physicals, sick and specialty office visits, observation care, inpatient care, newborn services, home visits, and related procedures. It applies across lines of business: Medicaid, INTEGRITY (Medicare), and Commercial.

Medical necessity: All services must be medically necessary to qualify for reimbursement. Neighborhood may use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP) to determine medical necessity.

Key directions: Providers are responsible for verifying eligibility, coverage, and authorization criteria prior to rendering services and are directed to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies; Provider Services is available for questions.

Key Thresholds and Limits

Critical Care Minimum Time>= 30 minutes

Critical Care Transport (Pediatric) Minimum Time> 30 minutes

Prolonged Inpatient Service Minimum Billable>= 15 minutes

Pediatric Fluoride Varnish Limits (Medicaid)<= 4 units per rolling year

Pediatric Fluoride Varnish Limits (Commercial)<= 4 units per plan year

Care Plan Oversight Limit1 unit per month

Chronic Care Management (INTEGRITY) Billing Time>= 20 minutes per month

G2082/G2083 Observation RequirementIncludes 2 hours post-administration observation

Medical-Necessity Criteria

General Medical Necessity

All services must be medically necessary to qualify for reimbursement. Neighborhood may use the following criteria to determine medical necessity:

ALL of the following

National Coverage Determination (NCD) compliance
Local Coverage Determination (LCD) compliance
Industry accepted criteria such as InterQual
Rhode Island EOHHS recommendations
Neighborhood Clinical Medical Policies (CMP)

Coding

Autologous Fat Grafting Covered Procedure CodesCPTCovered

15771	Autologous fat grafting; breast
15772	Autologous fat grafting; other site(s)

Diagnosis Codes Required for Autologous Fat GraftingICD-10Covered

C50.011
C50.929
N65.0
N65.1
Z42.1
Z92.21
Z92.3

Adult Routine Office Visit Diagnosis CodesICD-10Covered

Z00.00	General adult exam, unspecified
Z00.01	General adult exam, with abnormal findings

Adult Routine Office Visit CPT Codes (Table 1)CPT|HCPCSCovered

99385	Initial comprehensive preventive medicine eval; 18-39 yrs
99386	Initial comprehensive preventive medicine eval; 40-64 yrs
99387	Initial comprehensive preventive medicine eval; 65+ yrs
99395	Periodic preventive medicine reevaluation; 18-39 yrs
99396	Periodic preventive medicine reevaluation; 40-64 yrs
99397	Periodic preventive medicine reevaluation; 65+ yrs
G0438	Annual wellness visit; initial
G0439	Annual wellness visit; subsequent

Pediatric Preventive Office Visit Diagnosis CodesICD-10Covered

Z00.00
Z00.01
Z00.110
Z00.129
Z76.1
Z76.2

Pediatric Preventive CPT Codes (Table 2)CPTCovered

99381	Initial comprehensive preventive eval; infant <1 yr
99382	Initial comprehensive preventive eval; 1-4 yrs
99383	Initial comprehensive preventive eval; 5-11 yrs
99384	Initial comprehensive preventive eval; 12-17 yrs
99385	Initial comprehensive preventive eval; 18-39 yrs
99391	Periodic preventive reevaluation; infant <1 yr
99392	Periodic preventive reevaluation; 1-4 yrs
99393	Periodic preventive reevaluation; 5-11 yrs
99394	Periodic preventive reevaluation; adolescent 12-17 yrs
99395	Periodic preventive reevaluation; 18-39 yrs

Pediatric Developmental & Autism Screening Diagnosis CodesICD-10Covered

Z00.121
Z00.129

Pediatric Developmental Screening CPT Codes (Table 3)CPTCovered

96110

Developmental screening with scoring and documentation

Pediatric Fluoride Varnish Diagnosis CodeICD-10Covered

Z29.3

Encounter for prophylactic vaccination and inoculation; topical fluoride

Pediatric Fluoride Varnish CPT/HCPCS (Table 4)CPT|HCPCSCovered

99188	Application of topical fluoride varnish by physician or qualified professional
D1206	Topical fluoride varnish; therapeutic application

Prenatal Pediatrician Office Visit Diagnosis CodeICD-10Covered

Z76.81

Prenatal Pediatrician Office Visit CPT Codes (Table 5 excerpt)CPTCovered

99201	Office visit new patient, problem focused; typically 10 minutes
99202	Office visit new patient, expanded problem focused; typically 20 minutes
99203	Office visit new patient, detailed; typically 30 minutes
99241	Office consultation, problem focused; typically 15 minutes
99242	Office consultation, expanded problem focused; typically 30 minutes

Newborn Services Diagnosis CodesICD-10Covered

Z38.00
Z38.8

Newborn Services CPT Codes (Table 6 excerpt)CPTCovered

99184	Initiation of selective head or total body hypothermia in critically ill neonate
99460	Initial hospital or birthing center care, per day, normal newborn
99461	Initial care per day for normal newborn seen in other than hospital or birthing center
99462	Subsequent hospital care per day for normal newborn
99463	Initial hospital or birthing center care, per day for newborn admitted and discharged same date
99464	Attendance at delivery and initial stabilization of newborn
99465	Delivery/birthing room resuscitation

All Other Physician Services CPT Codes (Table 7 excerpt)CPTCovered

11719	Trimming of nondystrophic nails
11720	Debridement of nails; 1-5
11721	Debridement of nails; 6 or more
36415	Collection of venous blood by venipuncture
95249	Ambulatory CGM patient-provided equipment
95250	Ambulatory CGM office provided equipment
95251	Ambulatory CGM analysis, interpretation and report
96040	Medical genetics and genetic counseling services, each 30 minutes
96127	Brief emotional/behavioral assessment
96160	Administration of patient-focused health risk assessment instrument

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Excluded CPT/ServicesCPTNot Covered

36416	Capillary blood specimen collection (not reimbursable)
99241-99245	Consultation Services (excluded)
99251-99255	Consultation Services (excluded)
G0425-G0427	Consultation Services (excluded)
99211	99211 not reimbursable when billed same day as chemotherapy, non-chemotherapy infusion or injection (with or without modifier 25)

ED / Emergency and Critical Care E/MCPT

99282	Emergency department visit; expanded problem focused history/exam; medical decision making low complexity
99283	Emergency department visit; expanded problem focused history/exam; medical decision making moderate complexity
99284	Emergency department visit; detailed history/exam; medical decision making moderate complexity; high severity
99285	Emergency department visit; comprehensive history/exam; medical decision making high complexity; immediate significant threat
99291	Critical care; first 30-74 minutes
99292	Critical care; each additional 30 minutes

Domiciliary/Rest Home VisitsCPT

99324	Domiciliary/rest home visit new patient; problem focused history/exam; straightforward MDM; ~20 minutes
99325	Domiciliary/rest home visit new patient; expanded problem focused; MDM low complexity; ~30 minutes
99326	Domiciliary/rest home visit new patient; detailed history/exam; MDM moderate complexity; ~45 minutes
99327	Domiciliary/rest home visit new patient; comprehensive history/exam; MDM moderate complexity; ~60 minutes
99328	Domiciliary/rest home visit new patient; comprehensive history/exam; MDM high complexity; ~75 minutes
99334	Domiciliary/rest home visit established patient; problem focused; ~15 minutes
99335	Domiciliary/rest home visit established patient; expanded problem focused; ~25 minutes
99336	Domiciliary/rest home visit established patient; detailed; ~40 minutes
99337	Domiciliary/rest home visit established patient; comprehensive; ~60 minutes

Home VisitsCPT

99341	Home visit new patient; problem focused; ~20 minutes
99342	Home visit new patient; expanded problem focused; ~30 minutes
99343	Home visit new patient; detailed; ~45 minutes
99344	Home visit new patient; comprehensive; ~60 minutes
99345	Home visit new patient; comprehensive high complexity; ~75 minutes
99347	Home visit established patient; problem focused; ~15 minutes
99348	Home visit established patient; expanded problem focused; ~25 minutes
99349	Home visit established patient; detailed; ~40 minutes
99350	Home visit established patient; comprehensive; ~60 minutes

Prolonged and Standby ServicesCPT

99354	Prolonged E/M or psychotherapy in office/outpatient; first hour (add-on)
99355	Prolonged E/M or psychotherapy in office/outpatient; each additional 30 minutes (add-on)
99356	Prolonged service inpatient/observation; first hour (add-on)
99357	Prolonged service inpatient/observation; each additional 30 minutes (add-on)
99358	Prolonged E/M service before/after direct patient care; first hour
99359	Prolonged E/M service before/after direct patient care; each additional 30 minutes
99360	Standby service requiring prolonged attendance; each 30 minutes

Team Conferences and Supervision (Home/Hospice/Nursing Facility)CPT

99367	Medical team conference with interdisciplinary team, physician; 30+ minutes
99368	Medical team conference with interdisciplinary team, nonphysician; 30+ minutes
99374	Supervision of patient under home health agency; 15-29 minutes per calendar month
99375	Supervision of patient under home health agency; 30+ minutes per calendar month
99377	Supervision of hospice patient; 15-29 minutes per calendar month
99378	Supervision of hospice patient; 30+ minutes per calendar month
99379	Supervision of nursing facility patient; 15-29 minutes per calendar month
99380	Supervision of nursing facility patient; 30+ minutes per calendar month

Preventive Medicine E/MCPT

99386	Initial comprehensive preventive medicine E/M; new patient; 40-64 years
99387	Initial comprehensive preventive medicine E/M; new patient; 65+ years
99396	Periodic comprehensive preventive medicine; established patient; 40-64 years
99397	Periodic comprehensive preventive medicine; established patient; 65+ years

Preventive Counseling / Screening / BehavioralCPT|HCPCS

99401	Preventive medicine counseling/risk factor reduction; ~15 minutes
99402	Preventive medicine counseling/risk factor reduction; ~30 minutes
99403	Preventive medicine counseling/risk factor reduction; ~45 minutes
99404	Preventive medicine counseling/risk factor reduction; ~60 minutes
99406	Smoking/tobacco cessation counseling; intermediate >3 to 10 minutes
99407	Smoking/tobacco cessation counseling; intensive >10 minutes
99408	Alcohol/substance misuse structured screening and brief intervention; 15-30 minutes
99409	Alcohol/substance misuse structured screening and brief intervention; >30 minutes
99411	Preventive counseling in group setting; ~30 minutes
99412	Preventive counseling in group setting; ~60 minutes

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Prolonged Time / Care Management / Remote MonitoringCPT|HCPCS

99415	Prolonged clinical staff service during E/M in office/outpatient; first hour (add-on)
99416	Prolonged clinical staff service during E/M in office/outpatient; each additional 30 minutes (add-on)
99417	Prolonged outpatient E/M time when primary selected by total time; each 15 minutes (add-on)
99418	Prolonged inpatient/observation E/M time when primary selected by total time; each 15 minutes (add-on)
99451	Interprofessional telephone/Internet/EHR assessment and management by consultative physician; 5+ minutes; includes written report
99452	Interprofessional referral service by treating/requesting physician; 30 minutes
99453	Remote monitoring initial set-up & patient education
99454	Remote monitoring device supply with daily recordings/transmissions; each 30 days
99457	Remote physiologic monitoring treatment management services; first 20 minutes/month
99458	Remote physiologic monitoring; each additional 20 minutes/month (add-on)

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Interfacility Transport / Critical Care Pediatric and NeonatalCPT

99466	Critical care face-to-face during interfacility transport of critically ill/injured pediatric patient ≤24 months; first 30-74 minutes
99467	Critical care face-to-face during interfacility transport; each additional 30 minutes
99468	Initial inpatient neonatal critical care, per day; critically ill neonate ≤28 days
99469	Subsequent inpatient neonatal critical care, per day; critically ill neonate ≤28 days
99471	Initial inpatient pediatric critical care, per day; critically ill infant/young child 29 days–24 months
99472	Subsequent inpatient pediatric critical care, per day; 29 days–24 months
99475	Initial inpatient pediatric critical care, per day; 2–5 years
99476	Subsequent inpatient pediatric critical care, per day; 2–5 years
99477	Initial hospital care per day for neonate ≤28 days requiring intensive observation/interventions
99478	Subsequent intensive care per day for recovering very low birth weight infant (<1500g)

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Care Management and Chronic CareCPT|HCPCS

99487	Complex chronic care management; 60 minutes clinical staff time/month
99489	Complex chronic care management; each additional 30 minutes (add-on)
99490	Chronic care management services; at least 20 minutes clinical staff time/month
99491	Chronic care management personally provided by physician or QHP; at least 30 minutes/month
99495	Transitional care management; communication within 2 business days; MDM moderate; face-to-face within 14 days
99496	Transitional care management; communication within 2 business days; MDM high; face-to-face within 7 days
G0506	Comprehensive assessment and care planning for patients requiring chronic care management (list separately)
G0511	RHC/FQHC general care management; 20+ minutes clinical staff time/month
G0512	RHC/FQHC psychiatric collaborative care model; 60+ minutes clinical staff time/month
G2058	Chronic care management services; each additional 20 minutes clinical staff time/month (add-on)

Advance Care PlanningCPT

99497	Advance care planning; first 30 minutes face-to-face
99498	Advance care planning; each additional 30 minutes (add-on)

Diabetic Foot and Home INR Related HCPCSHCPCS

G0127	Trimming of dystrophic nails, any number
G0179	Physician re-certification for Medicare-covered home health services (patient not present), per re-certification period
G0180	Physician certification for Medicare-covered home health services (patient not present), per certification period
G0245	Initial physician evaluation/management of diabetic patient with LOPS
G0246	Follow-up physician evaluation/management of diabetic patient with LOPS
G0247	Routine foot care by physician of diabetic patient with LOPS
G0248	Demonstration prior to initiation of home INR monitoring for patients meeting Medicare criteria
G0250	Physician review/interpretation and patient management of home INR testing (includes up to four tests)

Substance Misuse Assessment HCPCSHCPCS

G0396	Alcohol/substance misuse structured assessment and brief intervention; 15-30 minutes
G0397	Alcohol/substance misuse structured assessment and intervention; >30 minutes

Annual Wellness / Preventive HCPCSHCPCS

G0438	Annual wellness visit; initial; includes personalized prevention plan of service (PPS)
G0439	Annual wellness visit; subsequent; includes personalized prevention plan of service (PPS)

RHC/FQHC Visit CodesHCPCS

G0463	Hospital outpatient clinic visit for assessment and management of a patient
G0466	Federally qualified health center (FQHC) visit, new patient
G0467	Federally qualified health center (FQHC) visit, established patient

Chronic Care Management and Related Care Management CodesHCPCS/CPT

G0511	RHC/FQHC only, general care management, 20 minutes or more clinical staff time/month
G0512	RHC/FQHC only, psychiatric collaborative care model, 60 minutes or more clinical staff time/month
G2058	Chronic care management services, each additional 20 minutes (add-on)
99490	Chronic care management (primary care) - referenced in guidance for use with G2058 and exclusions with 99487, 99489, 99491.
G2064	Comprehensive care management services for a single high risk disease; at least 30 minutes physician/QHP time/month
G2065	Comprehensive care management for a single high risk disease; at least 30 minutes clinical staff time/month

Prolonged Preventive ServicesHCPCS/CPT

G0513	Prolonged preventive service(s), first 30 minutes (list separately)
G0514	Prolonged preventive service(s), each additional 30 minutes

Esketamine Administration Visit CodesHCPCS/CPT

G2082	Office visit for established patient with supervision and provision of up to 56 mg esketamine; includes 2 hours post administration observation
G2083	Office visit for established patient with supervision and provision of >56 mg esketamine; includes 2 hours post administration observation

Office-based Opioid Use Disorder Treatment CodesHCPCS/CPT

G2086	Office-based treatment for OUD; at least 70 minutes first calendar month
G2087	Office-based treatment for OUD; at least 60 minutes subsequent calendar month
G2088	Office-based treatment for OUD; each additional 30 minutes beyond first 120 minutes

Miscellaneous Procedure and Clinic Visit CodesHCPCS/CPT

S0260	History and physical related to surgical procedure (list separately)
S0390	Routine foot care; removal/trimming of corns, calluses and/or nails
S0610	Annual gynecological exam, new patient
S0612	Annual gynecological exam, established patient
S0630	Removal of sutures by a physician other than original closer
T1015	Clinic visit/encounter, all-inclusive

Provider Actions & Billing Rules

Prior Authorization

Verify Eligibility and Authorizations

Verify member eligibility, coverage, and prior authorization requirements before rendering services. Providers should use Neighborhood's Prior Authorization Reference page and Clinical Medical Policies to confirm if a service requires prior authorization or has specific coverage criteria.

Check member-specific benefits and authorizations prior to service
Follow plan-specific prior authorization process and submission requirements
Reference Clinical Medical Policies for coverage criteria and medical necessity

Documentation Required

Medical Record Support

Medical record support may be requested. Neighborhood may request medical records to substantiate billed services and reimbursement. Providers should maintain documentation that meets CMS standards and be prepared to supply progress notes, time documentation, and any supporting records upon request.

Background

Background and scope: This physician services policy defines coverage, billing rules, frequency limits, documentation and reimbursement guidance across Medicaid, INTEGRITY (Medicare), and Commercial lines of business and covers services such as office visits, inpatient/observation care, critical care, newborn and pediatric preventive services, care management, and related CPT/HCPCS/ICD-10 coding.

References and standards: Neighborhood relies on external authorities and internal policies when determining medical necessity and billing compliance, including CMS/NCD/LCD, industry-accepted criteria such as InterQual, the Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP); specific coding, thresholds, and limits are stated in the policy tables and criteria trees.

Provider resources: Providers must verify eligibility and authorization requirements via Neighborhood's Prior Authorization Reference page and Clinical Medical Policies and may contact Provider Services (1-800-963-1001). Neighborhood reserves the right to request medical records and follows CMS documentation standards for payment determination.

Definitions

Care Plan Oversight (CPO)Physician supervision of a patient under home health, hospice, or nursing facility care involving review of reports, participation in care conferences, and development/revision of care plans and medical therapy

Critical Care30 minutes or more of direct physician care for critically ill/injured patients requiring high complexity medical decision-making to assess/manipulate/support vital organ function

Revision History

07/01/24revisedLatest

07/01/24 Annual review added autologous fat grafting, added more detail blood draw reimbursement, added additional requirements to Inpatient or Observation Hospital Visit section.

09/05/23revised

09/05/23 Annual Policy Review created new section for midlevel reimbursement, updated observation/inpatient requirements, added 99417 & 99418 to coding grid.

04/12/22revised

04/12/22 Annual Policy Review. Annual Gyn Codes added.