CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Evaluation and Management (E/M) billing and reimbursement guidelines

Governance of coding, documentation, and reimbursement rules for Evaluation and Management services (office, observation, inpatient, and prolonged services) affecting providers billing Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEvaluation and Management (E/M) billing and reimbursement guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionBill only one E/M code per practice per specialty per date of service; document and use modifiers when separate preventive and sick visit services occur the same day.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

oneE/M code allowed per practice/specialty per date of service

8-24hObservation stay duration to use 99234-99236

99354-99359Prolonged services codes

<30mProlonged services minimum billable time

oneMax prolonged codes per day

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E/M Coverage Criteria by Service Type

E/M coverage criteria by service type

Covered when the following service-specific criteria are met:

ALL of the following

Payment is allowed for only one Evaluation and Management (E/M) code per practice, per specialty type, per date of service.
If a preventive exam and an E/M code for a sick visit are billed on the same day, documentation may be required and a modifier indicating a separate service is required.
'New patient' is a patient who has not received services from the physician or another qualified health professional (with the same specialty or subspecialty) in the same practice within the last three (3) years.

ALL of the following

Payment is allowed for only one E/M code per practice, per specialty type, per date of service.
Services apply to new and established patients admitted to a hospital specifically for observation (a designated area is not required).
Only the physician who admits the patient to observation status can report the initial observation E/M code.
Services performed on the same date of service by the same provider are considered part of the initial observation care.
If the patient is admitted and discharged from observation on the same date, report codes 99234-99236; billing criteria require the stay be a minimum of eight hours but less than 24 hours, the billing physician must be present and personally provide the services, and admitting and discharge notes must be written by the billing physician.
If the patient is changed from observation to inpatient status on the same date, the physician cannot bill for a discharge management code (99217) or an outpatient visit for the observation unit care; if admitted on the same date as the initial observation, only the initial hospital visit may be billed by the physician.
If the patient is discharged on the second day, discharge day services are coded with the observation care discharge code; no observation discharge code is allowed if the patient was in observation for less than 8 hours.

ALL of the following

Payment is allowed for only one E/M code per practice, per specialty type, per date of service.
Initial services apply to new or established patients admitted to a hospital inpatient or a 'partial hospital' setting.
Reimbursement includes physician services provided while the patient was in observation status on the same date as the inpatient E/M service; when admitted and discharged on the same date, report codes 99234-99236 and the admitting provider should report only the initial hospital care code which includes any prior observation services provided that day by the admitting provider.
Subsequent services are services rendered outside of the initial admitting date.

ALL of the following

Prolonged services (CPT codes 99354-99359), with or without face-to-face contact, may be reimbursed and are billed in addition to a base E/M code.
Prolonged services are time-based codes; services less than 30 minutes in duration are not billable and are considered inclusive to the base E/M code.
The patient chart must clearly indicate time spent with the patient (face-to-face or without direct patient contact); time measurement need not be continuous.
Only one prolonged care code can be billed per day by the same physician or qualified health professional.
Notes may be requested to consider additional reimbursement; guidelines apply to all claim submission types and places of service where E/M codes are used.

CPT and Prolonged Service Codes

Prolonged servicesCPTCovered

99354-99359

Prolonged services with and without direct patient contact

Observation/Inpatient same-day admission and dischargeCPTCovered

99234-99236

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

Observation minimum hours to bill 99234-99236

Minimum observation durationMinimum of 8 hours but less than 24 hours

Billing codesUse CPT 99234-99236 for observation or inpatient care services including admission and discharge when criteria met

Physician requirementsBilling physician must be present and personally providing the services and must write admitting and discharge notes

If discharged next dayIf discharged on second day, use observation care discharge code; no discharge code allowed if observation <8 hours

Prolonged services minimum billable time

Minimum billable time30 minutes (prolonged services less than 30 minutes are not billable)

Provider Billing Rules and Required Actions

Billing Rule

Office visit billing rules

Payment is allowed for only one Evaluation and Management (E/M) code per practice, per specialty type, per date of service. If a preventive exam and an E/M for a sick visit are billed on the same day, documentation may be required to support separate payment and an appropriate modifier indicating a distinct service must be reported. A "new patient" is one who has not received services from the physician or another qualified health professional of the same specialty/subspecialty in the same practice within the last three (3) years.

One E/M per practice/specialty per date of service
Preventive + sick visit same day: require documentation and modifier to justify separate payment
New patient = no services from same specialty/subspecialty in same practice within 3 years

Billing Rule

Observation services billing rules

Payment is allowed for only one E/M code per practice, per specialty type, per date of service. Observation services apply to new and established patients admitted specifically for observation. Only the physician who admits the patient to observation status may report the initial observation E/M. Services provided by the same provider on the same date that are part of the observation stay are considered part of the initial observation care and are not separately billable.

Key Definitions

New patient — definition for billing/context

Definition'New patient' is a patient who has not received services from the physician or another qualified health professional (with the same specialty or subspecialty) in the same practice within the last three (3) years

ApplicabilityDefinition applies for determining appropriate E/M coding and billing status for office visits

DocumentationProvider records should reflect patient status (new vs established) consistent with the 3-year rule