CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Physician services (office, inpatient, observation, home visits, and related services)

Governs coverage and reimbursement rules for physician services (routine exams, sick visits, specialty office visits, observation and inpatient care, home visits, and related services) for Neighborhood Health Plan lines of business including Medicaid (excluding EFP), INTEGRITY, and Commercial.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysician services (office, inpatient, observation, home visits, and related services)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and obtain any required prior authorization before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=30critical care min time

3ynew patient lookback

1/yradult routine visit (Medicaid)

4pediatric fluoride units/yr

~100+listed CPTs in section

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.

Coverage and Medical Necessity Criteria

Chronic Care Management (INTEGRITY only)

ALL of the following

Care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Covered and reimbursable for INTEGRITY only according to CMS guidelines.
Provider billing rules
- Physicians, physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives may bill for at least 20 minutes or more of care coordination services per month.
  Use CPT 99490 for first 20 minutes; see G2058 for each additional 20 minutes as applicable.
- Only one practitioner can bill for CCM services per patient during any given month.
Billing and coding notes
- G2058 is reported for each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (do not report G2058 for <20 additional minutes).
  Do not report 99490 or G2058 in the same calendar month as 99487, 99489, or 99491.
- Chronic Care Management Services are excluded for Medicaid and Commercial members (see Exclusions).
  Covered only for INTEGRITY line of business.

Critical Care — general coverage criteria and rules

ALL of the following

Critical care is 30 minutes or more of direct care provided by a physician for a critically ill or critically injured patient.
All services less than 30 minutes should be billed with the appropriate E&M code.
Critical illness acutely impairs one or more vital organ systems such that there is a high probability of imminent or life‑threatening deterioration in the patient's condition.
Requires high complexity medical decision‑making to assess, manipulate and support vital organ system function.
Non‑separately reimbursable component services
- Arterial puncture
- Bladder aspiration

Critical Care Transport (Pediatric) — coverage criteria

ALL of the following

Neighborhood reimburses for attendance and direct face-to-face care by a physician during an interfacility transport of a critically ill or critically injured child age < 24 months, if the total time is greater than 30 minutes.
All services less than 30 minutes should be billed with the appropriate E&M code.
Non‑separately reimbursable component services for transport
- Gastric intubation
- Interpretation of blood gases and data stored in computers (e.g., ECGs, blood pressures, hematological data)
- Interpretation of cardiac output measurements

Not medically necessary — Neighborhood determination references

ALL of the following

All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCDs, LCDs, InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity.
It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services.
Contact Provider Services at 1-800-963-1001 for questions related to this policy.

Inpatient or Observation Visit Criteria — admission/discharge and visit billing rules

ALL of the following

The patient chart should clearly indicate the time spent with the patient face to face or without direct patient contact. Notes may be requested for consideration of additional reimbursement.
If a provider with a different specialty than the admitting provider sees the patient during the admission/observation stay, an initial inpatient/observation code should be used.
Observation stays must be a minimum of eight hours but less than 24 hours; billing physician must be present and personally providing services; admitting and discharge notes must be written by the billing physician.
If the patient is admitted and discharged from inpatient or observation status on the same date, use codes 99234-99236 (Observation or Inpatient Care Services, including admission and discharge).

New Patient Visit Eligibility — lookback period and eligibility rules

ALL of the following

New patient visits are reimbursed when the physician, or another physician of the same specialty within the same group, has not seen the patient within the last three (3) years.

Line-of-business diagnosis restrictions — diagnosis-based coverage differences

ANY of the following

Medicaid and INTEGRITY: Covered and reimbursable with no diagnosis restrictions.
Commercial: Covered and reimbursable for diabetic diagnosis codes E08.00 to E09.9 and E10.10 to E13.9 only.

Line-of-business coverage distinctions — coverage by payer/line of business

ANY of the following

Medicaid: Covered and reimbursable with no diagnosis restrictions.
INTEGRITY: Covered and reimbursable with no diagnosis restrictions (see Chronic Care Management and Critical Transport exceptions).
Commercial: Coverage limited as specified; verify commercial plan limits.

Preventive visit delivery and frequency criteria — preventive/routine visit limits

ALL of the following

Primary Care and preventive visit rules: Pediatric preventive office visits covered per EPSDT; vision and hearing screenings included and not separately reimbursable; pediatric fluoride varnish and screening limits apply as specified in Limitations.
Adult routine office visits: Covered once per year; frequency limits vary by line of business (Medicaid, INTEGRITY, Commercial).

Code Tables, Time Thresholds, and Limits

Observation/Inpatient Admission and Discharge CodesCPT

99234-99236

Observation or Inpatient Care Services (Including Admission and Discharge Services)

Commercial-only covered diabetic diagnosis codesICD-10Covered

E08.00-E09.9	Diabetes mellitus due to underlying condition, drug- or chemical-induced diabetes, other specified diabetes-related codes (Commercial coverage range listed)
E10.10-E13.9	Type 1, Type 2, and other specified diabetes codes (Commercial coverage range listed)

Adult routine/preventive visit diagnosis and CPT/G codesmixedCovered

Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings
99385	Initial comprehensive preventive medicine evaluation and management, new patient; 18-39 years
99386	Initial comprehensive preventive medicine evaluation and management, new patient; 40-64 years
99387	Initial comprehensive preventive medicine evaluation and management, new patient; 65 years and older
99395	Periodic comprehensive preventive medicine reevaluation and management, established patient; 18-39 years
99396	Periodic comprehensive preventive medicine reevaluation and management, established patient; 40-64 years
99397	Periodic comprehensive preventive medicine reevaluation and management, established patient; 65 years and older
G0438	Annual wellness visit; initial visit
G0439	Annual wellness visit; subsequent visit

Pediatric preventive visit diagnosis and CPT codes (Table 2)mixedCovered

Z00.00	See Table 2 — pediatric preventive visit diagnosis
Z00.01	See Table 2 — pediatric preventive visit diagnosis
Z00.110	Health examination for newborn under 8 days
Z00.129	Encounter for routine child health examination, unspecified
Z76.1	Persons encountering health services in other specified circumstances
Z76.2	Administrative examinations
99381	Initial comprehensive preventive medicine evaluation and management, new patient; infant
99382	Initial comprehensive preventive medicine evaluation and management, new patient; early childhood
99383	Initial comprehensive preventive medicine evaluation and management, new patient; late childhood
99384	Initial comprehensive preventive medicine evaluation and management, new patient; adolescent

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Screening and excluded codesmixed

96160	CRAFFT screening test
96161	Maternal depression screening (Edinburg) billed under infant's member ID
96127	Brief emotional/behavioral assessment (e.g., PHQ-9 variant) — depression screen limit
99211	Office or other outpatient visit for the evaluation and management of an established patient — excluded when billed same day as infusion/injection
99241-99245	Consultation Services — excluded
99251-99255	Consultation Services — excluded
G0425-G0427	Consultation Services — excluded

Preventive E/M CodesCPTCovered

99381	Initial comprehensive preventive medicine evaluation and management, new patient; infancy
99382	Initial comprehensive preventive medicine evaluation and management, new patient; early childhood (age 1 through 4 years)
99383	Initial comprehensive preventive medicine evaluation and management, new patient; late childhood (age 5 through 11 years)
99384	Initial comprehensive preventive medicine evaluation and management, new patient; adolescent (age 12 through 17 years)
99385	Initial comprehensive preventive medicine evaluation and management, new patient; 18-39 years
99391	Periodic comprehensive preventive medicine reevaluation and management, established patient; infant (<1 year)
99392	Periodic comprehensive preventive medicine reevaluation and management, established patient; early childhood (1-4 years)
99393	Periodic comprehensive preventive medicine reevaluation and management, established patient; late childhood (5-11 years)
99394	Periodic comprehensive preventive medicine reevaluation and management, established patient; adolescent (12-17 years)
99395	Periodic comprehensive preventive medicine reevaluation and management, established patient; 18-39 years

Table 3 - Developmental ScreeningCPTCovered

96110

Developmental screening, with scoring and documentation, per standardized instrument

Table 4 - Pediatric Fluoride VarnishCPT|HCPCSCovered

99188	Application of topical fluoride varnish by a physician or other qualified health care professional
D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

Office/Outpatient E/M Codes (Table 5 / All Other Services)CPTCovered

99201	Office/outpatient visit new patient, problem focused, straightforward MDM, ~10 minutes
99202	Office/outpatient visit new patient, expanded problem focused, straightforward MDM, ~20 minutes
99203	Office/outpatient visit new patient, detailed history/exam, low complexity MDM, ~30 minutes
99204	Office/outpatient visit new patient, comprehensive history/exam, moderate complexity MDM
99205	Office/outpatient visit new patient, comprehensive history/exam, high complexity MDM, ~60 minutes
99211	Office/outpatient visit established patient, minimal, ~5 minutes
99212	Office/outpatient visit established patient, problem focused, straightforward MDM, ~10 minutes
99213	Office/outpatient visit established patient, expanded problem focused, low complexity MDM, ~15 minutes
99214	Office/outpatient visit established patient, detailed history/exam, moderate complexity MDM, ~25 minutes
99215	Office/outpatient visit established patient, comprehensive history/exam, high complexity MDM

Table 6 - Newborn ServicesCPTCovered

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

Table 7 / All Other Physician ServicesCPTCovered

11719	Trimming of nondystrophic nails, any number
11720	Debridement of nail(s); 1 to 5
11721	Debridement of nail(s); 6 or more
36415	Collection of venous blood by venipuncture
95249	Ambulatory continuous glucose monitoring, patient-provided equipment, sensor placement, etc.
95250	Ambulatory continuous glucose monitoring, office-provided equipment, sensor placement, etc.
95251	Ambulatory continuous glucose monitoring analysis, interpretation and report
96040	Medical genetics and genetic counseling services, each 30 minutes face-to-face
96127	Brief emotional/behavioral assessment, with scoring and documentation
96160	Administration of patient-focused health risk assessment instrument

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Covered CPT CodesCPTCovered

99214	Office or other outpatient visit for established patient; requires 2 of 3: detailed history, detailed exam, medical decision making of moderate complexity; counseling/coordination; typically 15 minutes
99215	Office or other outpatient visit for established patient; requires 2 of 3: comprehensive history, comprehensive exam, medical decision making of high complexity; typically 25 minutes
99221	Initial hospital inpatient or observation care, per day; medically appropriate history/exam and straightforward or low level MDM; total time when used: 40 minutes
99222	Initial hospital inpatient or observation care, per day; medically appropriate history/exam and moderate MDM; total time when used: 55 minutes
99223	Initial hospital inpatient or observation care, per day; medically appropriate history/exam and high MDM; total time when used: 75 minutes
99231	Subsequent hospital inpatient or observation care, per day; straightforward or low level MDM; total time when used: 25 minutes
99232	Subsequent hospital inpatient or observation care, per day; moderate MDM; total time when used: 35 minutes
99233	Subsequent hospital inpatient or observation care, per day; high MDM; total time when used: 50 minutes
99234	Hospital inpatient/observation care including admission and discharge same date; straightforward or low MDM; total time when used: 45 minutes
99235	Hospital inpatient/observation care including admission and discharge same date; moderate MDM; total time when used: 70 minutes

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Listed CPT CodesCPT

99401	Preventive medicine counseling; ~15 minutes
99402	Preventive medicine counseling; ~30 minutes
99403	Preventive medicine counseling; ~45 minutes
99404	Preventive medicine counseling; ~60 minutes
99406	Smoking/tobacco cessation counseling; >3 to 10 minutes
99407	Smoking/tobacco cessation counseling; >10 minutes
99408	Alcohol/substance abuse structured screening and brief intervention; 15–30 minutes
99409	Alcohol/substance abuse structured screening and brief intervention; >30 minutes
99411	Preventive medicine counseling in group; ~30 minutes
99412	Preventive medicine counseling in group; ~60 minutes

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Listed HCPCS/G/S/T/S CodesHCPCS

G0127	Trimming of dystrophic nails, any number
G0179	Physician recertification for Medicare-covered home health services (patient not present)
G0180	Physician certification for Medicare-covered home health services (patient not present)
G0245	Initial physician E/M of diabetic patient with diabetic sensory neuropathy resulting in LOPS (includes required elements)
G0246	Follow-up physician E/M of diabetic patient with diabetic sensory neuropathy resulting in LOPS (includes required elements)
G0247	Routine foot care by a physician of diabetic patient with LOPS including local care of superficial wounds, debridement of corns/calluses, trimming/debridement of nails
G0248	Demonstration prior to initiation of home INR monitoring for qualifying patients
G0250	Physician review, interpretation, and patient management of home INR testing; testing not more frequently than once a week; billing units include four tests
G0396	Alcohol/substance misuse structured assessment and brief intervention 15–30 minutes
G0397	Alcohol/substance misuse structured assessment and intervention >30 minutes

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Critical care / Critical care transport minimum time

Minimum time to bill critical care (adult)>= 30 minutes of direct physician care for a critically ill or injured patient

Minimum time to bill pediatric critical care transport> 30 minutes total face-to-face care during interfacility transport for child <24 months

When <30 minutesServices less than 30 minutes should be billed with the appropriate E&M code

Provider Responsibilities, Documentation, and Denial Risks

Note

Prerequisites and Medical Necessity

All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCDs, LCDs, InterQual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity. Services deemed not medically necessary are not reimbursable. Providers must verify member eligibility, benefit coverage, and any prior authorization requirements before rendering services. For plan-specific prior authorization details and clinical policies, refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies or contact Provider Services at 1-800-963-1001.

Services not medically necessary are not reimbursable; Neighborhood may review records against NCD/LCD/InterQual/CMP/EOHHS criteria.
Providers must verify eligibility, coverage and authorization prior to rendering services.
See Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for authorization rules.

Prior Authorization

Prior Authorization and Eligibility Verification Required

Prior authorization and eligibility verification are required when specified by the member's benefit plan or Neighborhood prior authorization references. Claims are subject to checks for authorization prior to payment.

Policy Scope and Background

This policy governs physician services across multiple care settings including office/outpatient visits, emergency department, inpatient and observation stays, nursing facility care, newborn services, home/domiciliary visits and related services. It clarifies billing and reimbursement rules that apply across these settings — for example, time thresholds for critical care and prolonged services, components that are not separately reimbursable when included in a bundled service, documentation expectations, and special coverage rules for chronic care management and preventive services. The scope applies to Neighborhood Health Plan lines of business including Medicaid (excluding EFP), INTEGRITY, and Commercial.

Key Definitions and Terms

Care Plan Oversight (CPO) definition

DefinitionCare Plan Oversight (CPO) is 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 for complex or multidisciplinary care

ComponentsIncludes review of patient status reports, participation in care conferences, and medical therapy oversight

SettingApplies to home health agencies, hospice, and nursing facilities

Critical care definition (>= 30 minutes)

DefinitionCritical care is 30 minutes or more of direct physician care for a critically ill or injured patient requiring high complexity medical decision-making

Clinical contextCritical illness impairs one or more vital organ systems with high probability of imminent or life-threatening deterioration

Document Revision History

2023-09-05Annual Policy ReviewLatest

Created new section for midlevel reimbursement, updated observation/inpatient requirements, and added CPT codes 99417 and 99418 to the coding grid.

2022-04-12Annual Policy Review

Performed annual policy review and added annual gynecological codes.

2021-06-08Update

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysician services (office, inpatient, observation, home visits, and related services)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and obtain any required prior authorization before rendering services.

SourceLink

On This Page

Bladder catheterization

Cardiac output measurements

Chest X‑ray interpretation

Continuous positive airway pressure (CPAP)

Endotracheal intubation

IV fluid administration

Oral or nasogastric tube placement

Peripheral venous access

Transcutaneous pacing

Ventilator management

Provider actions / billing rules

Bill critical care codes only when ≥30 minutes of physician direct critical care time is provided; otherwise bill appropriate E&M code for time <30 minutes.
Services that are components of critical care are not separately reimbursable when billed with critical care on the same date of service by the same provider.

Interpretation of chest x‑rays

Interpretation of pulse oximetry

Routine monitoring evaluations (vital signs and cardiac monitoring)

Temporary cardiac transcutaneous pacing

Vascular access procedures

Ventilator management

Critical Transport Services are excluded for INTEGRITY members (see Exclusions).

Verify line‑of‑business coverage before billing.

Chronic Care Management monthly minimum billed time (INTEGRITY)

Minimum monthly billed time (INTEGRITY)At least 20 minutes of care coordination services per calendar month (billable by physicians, PAs, clinical nurse specialists, NPs, CNMs)

Single biller ruleOnly one practitioner may bill CCM services per patient per month

G2058 reporting noteDo not report G2058 for less than 20 minutes additional to the first 20 minutes in a month; use G2058 with 99490 when appropriate

Billable prolonged services minimum increment

Minimum billable increment for prolonged services>= 15 minutes; services less than 15 minutes are not billable and are considered inclusive to the base E/M allowance

Time-based codingProlonged services are billed in addition to a base E/M code and time need not be continuous

One prolonged code per dayOnly one prolonged care code can be billed per day by the same physician or qualified health professional

Maternal Depression Screening units limit

Units limitMaternal Depression Screening (CPT 96161) limited to 4 units per rolling year

Billing contextMaternal depression screen may be billed under the infant's member ID per document references

Related codesDepression screening CPTs (96127) have separate frequency limits (see CPT 96127 block)

Pediatric Fluoride Varnish units limit

Annual units limitPediatric fluoride varnish (codes 99188 / D1206) limited to 4 units per year

Age and diagnosis requirementCovered for ages 6 months through 18.99 years and must be billed with diagnosis Z29.3

CodesUse CPT 99188 or HCPCS D1206 as listed in Table 4

Depression Screen (CPT 96127) frequency

Frequency limit (96127)Depression screen (CPT 96127) limited to one (1) screening per rolling year

Related screening limitsSeparate limits apply for substance use screening (CPT 96160) and maternal depression (CPT 96161)

Billing guidanceEnsure required diagnosis codes and documentation accompany screening claims to avoid denial

Time thresholds for inpatient/outpatient E/M codes — examples

Example inpatient initial care times99221 = total time >= 40 minutes; 99222 = >= 55 minutes; 99223 = >= 75 minutes

Example subsequent inpatient times99231 = >= 25 minutes; 99232 = >= 35 minutes; 99233 = >= 50 minutes

Same-day admission/discharge examples99234 = >= 45 minutes; 99235 = >= 70 minutes; 99236 = >= 85 minutes

Time thresholds for E/M code selection — exact minute values per code

Exact minute values for total time selection99221=40; 99222=55; 99223=75; 99231=25; 99232=35; 99233=50; 99234=45; 99235=70; 99236=85; 99238=30

Use of total timeWhen using total time on date of encounter for code selection, these minute thresholds must be met or exceeded

ED/office typical timesOffice/ED codes have typical face-to-face times (e.g., 99214 ~15 min; 99215 ~25 min) to guide selection

Typical face-to-face time for 99483

Typical face-to-face time for 99483Approximately 50 minutes (typical) for assessment and care planning for cognitive impairment

Required elements99483 includes multiple required elements (cognition-focused evaluation, functional assessment, standardized staging instruments, medication reconciliation, caregiver assessment, written care plan)

SettingApplies in office/outpatient, home, domiciliary or rest home settings

Chronic care management minimum monthly clinical staff time (99490)

Minimum clinical staff time for 99490>= 20 minutes of clinical staff time per calendar month (directed by physician or QHP)

Code elements99490 requires multiple chronic conditions expected to last >=12 months and comprehensive care plan elements

G2058 interactionG2058 is used for each additional 20 minutes in conjunction with 99490; do not report G2058 for <20 minutes additional

Complex chronic care management minimum monthly clinical staff time (99487)

Minimum clinical staff time for 9948760 minutes of clinical staff time directed by a physician or QHP per calendar month

Required elementsMultiple (2+) chronic conditions, establishment/substantial revision of comprehensive care plan, moderate or high complexity MDM

Add-on 9948999489 represents each additional 30 minutes of clinical staff time per calendar month (list separately)

Remote physiologic monitoring first interval (99457/99458)

First interval99457 = first 20 minutes per calendar month of remote physiologic monitoring treatment management (requires interactive communication)

Additional interval99458 = each additional 20 minutes per calendar month (list separately in addition to primary code)

Billing note99457/99458 time is measured per calendar month and requires interactive communication with patient/caregiver

Prior authorization and eligibility verification required (coding/provider action overlap)

Verify eligibility and prior authorizationProviders must verify member eligibility, coverage and obtain/document any required prior authorization prior to rendering services

Claims must follow coding standardsClaims must follow contractual timely filing and coding standards per CPT, ICD-10-CM, and HCPCS

Reference resourcesRefer to Neighborhood's plan-specific Prior Authorization Reference page and Telemedicine Payment Policy for telemedicine rules

Verify authorization requirements via Neighborhood's Prior Authorization Reference page.
Claims lacking required prior authorization may be denied or reduced.

Prior Authorization

Telemedicine Prior Authorization Reference

Telemedicine services may have distinct prior authorization and billing rules. Providers must follow the Telemedicine Payment Policy for coverage, prior authorization, and coding guidance.

Refer to the Telemedicine Payment Policy for prior authorization and billing rules for telemedicine services.

Billing Rule

Newborn Services — Billing Codes and Diagnosis Requirement

Newborn services must be billed with a qualifying newborn diagnosis (Z38.00–Z38.8) in addition to the appropriate newborn service code from Table 6. Correct pairing of diagnosis and procedure codes is required for reimbursement.

Required neonatal diagnosis range: Z38.00–Z38.8
See Table 6 for allowed newborn CPT codes (e.g., 99460, 99461, 99462, 99463, 99464, 99465 and 99184).
Claims without the required Z38.xx diagnosis may be denied.

Billing Rule

Blood Draw — Routine Venipuncture Billing

Routine venipuncture (blood draw) is not separately reimbursable when billed on the same date as an E/M service. Billing capillary blood specimen collection (CPT 36416) is listed as excluded in this policy; providers should not bill routine venipuncture separately with E/M visits.

Routine venipuncture is not separately reimbursable when billed with an E/M service.
Capillary blood specimen collection (CPT 36416) is excluded — do not bill separately with E/M.

Documentation Required

Documentation and Medical Records

Documentation must support the services billed and the medical necessity of those services. Neighborhood may request medical records and may audit claims. Documentation should follow CMS standards and may be required for payment consideration.

Neighborhood reserves the right to request medical records for any billed service.
Documentation must support billed codes and medical necessity and follow CMS documentation standards.

Documentation Required

Document Time Spent for Prolonged Services

For prolonged services, the patient chart must clearly indicate the time spent face-to-face or without direct patient contact. Time-based prolonged services are reimbursable only when documentation shows the duration and meets CPT rules (services <15 minutes are not billable). Medical notes may be requested for review.

Document start/stop times or total time for prolonged services and indicate face-to-face vs non-face-to-face elements.
Services under 15 minutes are not billable and are considered inclusive to the base E/M.
Only one prolonged care code can be billed per day by the same practitioner.

Documentation Required

Preventive Evaluation & Management Documentation

Preventive E/M services (CPT 99381–99395 and 99391–99394 series) require history, examination, counseling/anticipatory guidance/risk reduction, and ordering of appropriate labs or diagnostics. Typical times and component expectations should be documented in the medical record.

Preventive visit documentation must include age-appropriate history, exam, counseling/anticipatory guidance, and any ordered labs/diagnostics.
Record the typical time spent and elements performed that support the selected preventive E/M code.

Documentation Required

Required Documentation for Diabetic Foot Codes (G0245–G0247)

Required documentation for diabetic foot evaluation codes (G0245–G0247) must include diagnosis of loss of protective sensation (LOPS), patient history, focused foot examination elements (visual inspection, protective sensation evaluation, foot structure/biomechanics, vascular status and skin integrity), footwear evaluation/recommendation, and patient education as applicable.

G0245 requires diagnosis of LOPS plus history, exam elements, footwear recommendation, and education.
G0246 requires follow-up elements including history, exam with specified components, and education.
G0247 supports routine foot care with documentation of local wound care, debridement if present, and nail care as applicable.

Denial Risk

Potential Denial Triggers

Potential denial triggers include lack of member eligibility, failure to obtain required prior authorization, insufficient or missing documentation, timely filing violations, bundling/duplicate billing, and services excluded by this policy. Claims are also subject to claims payment edit rules, coding guidelines, provider contract terms, and state/federal regulations.

Claims may be denied for missing prior authorization when required, ineligibility, or benefit exclusions.
Insufficient documentation or failure to produce records upon request can result in denial or recoupment.
Timely filing limits and coding/claim edit failures are common denial causes.

Note

No Additional Prior Authorization Specified

Not all content in this section imposes additional authorization or coverage constraints beyond standard requirements. When a specific prior authorization or exclusion is not specified here, follow the plan's general prior authorization and coverage rules.

If prior authorization is not specified for a service in this section, standard plan prior authorization rules still apply.
Providers should consult the Prior Authorization Reference page for any service-level uncertainties.

Denial Risk

Denial Risk — Claim Payment Conditions

Claim payments remain subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edits, coding and documentation guidelines, authorization policies, provider contracts, and applicable regulations. This policy is informational and not a guarantee of payment; Neighborhood may update the policy and audit services.

Payments are subject to eligibility, coding edits, documentation, authorization, contracts, and state/federal rules.
This policy is informational only and does not guarantee reimbursement; Neighborhood may audit billed services.

Billing Rule

Pediatric Fluoride Varnish Billing

Pediatric fluoride varnish must be billed with diagnosis Z29.3 in addition to a fluoride varnish procedure code (see Table 4). Table 4 includes CPT 99188 and HCPCS D1206. Ensure correct diagnosis and procedure code pairing to avoid denials.

Pediatric fluoride varnish diagnosis: Z29.3
Table 4 procedure codes: 99188 and D1206
Claims missing the required Z29.3 diagnosis paired with the varnish code may be denied.

Billing guidanceServices less than 30 minutes should be billed with the appropriate E&M code; specified components are not separately reimbursable

Chronic Care Management (CCM) definition

DefinitionChronic Care Management (CCM) are care coordination services outside regular office visits for patients with two or more chronic conditions expected to last at least 12 months or until death and placing the patient at significant risk

Coverage noteCovered for INTEGRITY only per CMS guidelines; specific CCM CPT/G codes define required time elements

Required elementsIncludes establishment/monitoring of comprehensive care plan and directed clinical staff time per code descriptors

Developmental screening (96110) definition

DefinitionDevelopmental screening (96110): Developmental screening with scoring and documentation per standardized instrument

Billing requirementMust be billed with appropriate pediatric encounter diagnosis codes (e.g., Z00.121 or Z00.129) and Table 3 code

Use caseExamples include developmental milestone surveys and speech/language delay screens

Fluoride varnish (99188 / D1206) definition

DefinitionFluoride varnish (99188 / D1206): Application of topical fluoride varnish by a qualified health care professional; D1206 is topical fluoride for moderate to high caries risk patients

Units and limitsLimited to 4 units per year; must be billed with diagnosis Z29.3 for pediatric patients

Applicable ageCovered for ages 6 months through 18.99 years (per Limitations section)

Medical decision making levels definition

DefinitionMedical decision making (MDM) levels are described per code as straightforward, low, moderate, or high complexity corresponding to code-specific requirements

Role in code selectionMDM level is one of the key components used to determine E/M code selection along with history and exam when time-based selection is not used

ExamplesCodes list MDM expectations (e.g., 99214 moderate complexity; 99215 high complexity)

Typical time for code selection — guidance across codes

Guidance for time-based selectionTypical and minimum times are provided across codes to guide selection when using total time (eg, 99214 ~15 min; 99215 ~25 min; 99221=40 min when using total time)

Use across settingsApplies to office/ED, inpatient/observation, and other settings where total time selection is permitted

DocumentationMedical record should document total time on date of encounter when time is used for code selection

Chronic care management codes (99490, 99487, 99489, 99491, G2058, G2064, G2065) — summary of requirements

Code list and minimum time elements99490 (>=20 min clinical staff/month); 99487 (60 min clinical staff/month); 99489 (each additional 30 min); 99491 (>=30 min physician/QHP/month); G2058 (each additional 20 min with 99490); G2064/G2065 (>=30 min for single high-risk disease)

Coverage constraintsDo not report G2058 for <20 minutes additional and do not report 99490 or G2058 in same month as 99487/99489/99491

Required elementsCodes require multiple chronic conditions, comprehensive care plan establishment/revision, and specified time directed by physician or QHP

Diabetic sensory neuropathy with loss of protective sensation (LOPS) — definition and examination elements

Definition of LOPSDiabetic sensory neuropathy with loss of protective sensation (LOPS) requires diagnosis of LOPS plus history and a physical exam including inspection of forefoot/hindfoot/toe web spaces and evaluation of protective sensation

Required exam elementsAssessment must include inspection of foot areas, protective sensation testing, evaluation of foot structure/biomechanics, vascular status and skin integrity

Documentation necessityPhysician evaluation must document these elements to support codes such as G0245–G0247

Modified language for observation care.

2021-05-01Policy Effective Date

Policy effective date established.

2021-01-05Policy Review

Policy review performed.

2020-11-01Content updates and consolidation

Combined E&M, Critical Care, Pediatric Critical Care Transport, New vs Established Patient, Emergency Department Services, Observation E&M, Hospital Inpatient Services, and Physician Services policies and updated format.