CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Physician Services Reimbursement and Billing Guidance

Defines reimbursement rules and billing guidance for physician services (office visits, inpatient, observation, critical care, newborn, preventive and other physician services) across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysician Services Reimbursement and Billing Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Critical care min time

8Observation min hours

2Chronic conditions req'd (CCM)

2Prenatal pediatric visits covered

4/yrFluoride varnish limit

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.

Developmental/autism diagnosis

Coverage Criteria and Medical Necessity

inv-01: Applicability and general medical necessity

Applies to physician services across specified lines of business; services must be medically necessary.

Applies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business.

All services must be medically necessary; Neighborhood may use LCDs, NCDs, Interqual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.

Routine venipuncture (e.g., CPT 36416) is not separately reimbursable when included in an E/M service.

New patient office visit is only reimbursable if the patient has not been seen by the same specialty group within the prior 3 years (AMA definition of new patient applies).

See documentation requirements for medical record support.

Post-surgical visits related to the surgical global period are not separately reimbursable; unrelated post-operative visits may be billed with modifier 24 and must be supported by documentation.

Observation service rules: only the physician who admits to observation may report the initial observation E/M; observation stays must meet the defined time criteria (>= 8 and < 24 hours for observation) and admission/discharge documentation must be by the billing physician.

Prolonged services are payable when billed in addition to a base E/M; services under 30 minutes are not billable; only one prolonged code per day per same physician.

Critical care services require minimum time thresholds (e.g., first 30–74 minutes for code 99291) and critical care components are generally not separately reimbursable when included in critical care codes.

inv-02: Primary care and preventive services coverage criteria

Reimbursement rules and limits for office visits and preventive services

Pediatric preventive office visits are covered per the EPSDT schedule; vision and hearing screenings performed as part of the pediatric preventive visit are not separately reimbursable.

Neighborhood will reimburse a preventive visit and a sick visit on the same day when the sick visit is billed with modifier 25 and documentation supports a significant, separately identifiable E/M service.

Adult routine office visits are limited: INTEGRITY — one (1) per calendar year; Medicaid — one (1) per rolling year; Commercial — one (1) per calendar/plan year.

Pediatric fluoride varnish covered for members age 6 months through 18.99 years; limited to four (4) units per plan year (Commercial) and four (4) units per year rolling (Medicaid).

Screening limitations: CPT 96127 (depression screen) limited to one (1) per year; CPT 96160 (CRAFFT) and CPT 96161 (maternal depression) limited as specified in limitations; additional screening services beyond listed limits require prior authorization.

inv-03: Pediatric Developmental Screening criteria

Pediatric developmental screening must be billed with the specified diagnosis and screening code

Must be billed with diagnosis Z00.121.

Must be billed with a code from Table 3: CPT 96110 (developmental screening with scoring and documentation, per standardized instrument).

inv-04: Pediatric Autism Screening criteria

Pediatric autism screening must be billed with the autism screening diagnosis and table code with modifier

Must be billed with diagnosis Z00.121.

Table 3 code (e.g., CPT 96110) must be billed with modifier U1 for autism screening.

inv-05: Pediatric Fluoride Varnish criteria

Pediatric fluoride varnish must be billed with the fluoride diagnosis and a Table 4 code

Must be billed with diagnosis Z29.3.

Must be billed with a Table 4 code: CPT 99188 or HCPCS D1206.

Coverage limited to four (4) units per plan year for Commercial and four (4) units per year rolling for Medicaid.

inv-06: Prenatal Pediatrician Office Visit criteria

Prenatal pediatrician office visits require diagnosis Z76.81 and an appropriate E/M code from Table 5

Must be billed with diagnosis Z76.81.

Must be billed with an appropriate office/outpatient E/M code from Table 5 (examples include 99201–99205 and associated E/M codes as listed).

Visit limit: Prenatal pediatric office visits are covered for up to two visits (each up to 30 minutes) per member as specified.

inv-07: Newborn Services criteria

Newborn services require birth status diagnosis and codes from Table 6

Must be billed with a birth status diagnosis in the range Z38.00–Z38.8.

Must be billed with an appropriate newborn service code from Table 6 (examples include 99184, 99460–99465 and other newborn E/M codes listed).

inv-08: All Other Physician Services criteria

All other physician services must be billed with a code from Table 7

Services must be billed with an appropriate procedure code from Table 7 (extensive list of miscellaneous CPT/HCPCS codes such as 11719–11721, 36415, 95249–95251, 96127, 96160–96161, 98925–98929, 99050–99091, 99174–99177, 99201–99205, and others as listed).

Examples of included E/M and related codes

Subsequent hospital/observation care: 99231–99233.
Observation/admission and discharge codes: 99234–99236; discharge management 99238–99239.
Emergency department and critical care: 99281–99285; critical care 99291–99292.

inv-09: Listed E/M and related service codes and descriptors

This section enumerates procedure codes and descriptive billing elements; it documents the component requirements, typical times, and clinical context for E/M and related services.

Codes listed include but are not limited to: subsequent hospital care (99231–99233), observation/admission with same-day discharge (99234–99236), hospital discharge (99238–99239), ED E/M (99281–99285), critical care (99291–99292), domiciliary/home visit codes (99324–99328, 99341–99345, 99347–99350), prolonged services (99354–99359, 99358–99359), team conference and supervision codes (99367–99380), preventive medicine and counseling (99386–99397, 99401–99404), behavioral and remote monitoring codes (99406–99409, 99415–99416, 99451–99458), pediatric/neonatal critical care (99466–99480), and cognitive impairment assessment (99483).

Each code includes component requirements (history, exam, MDM), typical face-to-face time expectations, and contextual guidance on clinical severity or setting as documented in the code descriptors.

inv-10: General qualifiers and audit rules

General billing and payment qualifiers

Payments are informational and not a guarantee of reimbursement; claim payments are subject to member eligibility, benefit coverage, claim payment edit rules, coding and documentation guidelines, authorization policies, provider contract terms, and state and federal regulations.

All services billed are subject to audit; Neighborhood may request medical records and documentation to substantiate billed services and medical necessity.

Policy implementation may vary across electronic claims processing systems due to programming or other constraints; providers must follow contractual claim submission timeliness and national claims standards for adjustments and reconsiderations.

Codes, Limits and Time Thresholds

Observation/Inpatient and Prolonged Service codesCPT

99234-99236	Observation or Inpatient Care Services (Including Admission and Discharge Services)
99354-99359	Prolonged services (with and without face-to-face contact)

Chronic Care ManagementCPTCovered

Chronic Care Management (CCM)

Monthly CCM billed for >=20 minutes by eligible practitioners; only one practitioner per patient per month

Adult routine preventive visit codesCPTCovered

Z00.01	Adult routine preventive visit diagnosis
99385	Initial comprehensive preventive medicine evaluation - new patient 18-39
99386	Initial comprehensive preventive medicine evaluation - new patient 40-64
99387	Initial comprehensive preventive medicine evaluation - new patient 65+
99395	Periodic comprehensive preventive medicine - established 18-39
99396	Periodic comprehensive preventive medicine - established 40-64
99397	Periodic comprehensive preventive medicine - established 65+
G0438	Annual wellness visit; initial
G0439	Annual wellness visit; subsequent

Pediatric preventive visit codesCPTCovered

Z00.00	Pediatric preventive visit diagnosis (listed)
Z76.1	Encounter for health supervision and care of other healthy child
Z00.121	Pediatric developmental/autism screening diagnosis used in tables
99381	Initial preventive visit - infant
99382	Initial preventive visit - early childhood
99383	Initial preventive visit - late childhood
99384	Initial preventive visit - adolescent
99391	Periodic preventive visit - infant (established)
99392	Periodic preventive visit - early childhood (established)
99393	Periodic preventive visit - late childhood (established)

1–10 of 12

1/2

Screening CPT codes and limitsCPTCovered

96127	Brief emotional/behavioral assessment (depression screen) - limited to 1 per year
96160	CRAFFT substance use screening - INTEGRITY: 1 per rolling year for <21
96161	Maternal depression screening - limited to 4 units per year rolling

Table 3 - Developmental screeningCPTCovered

96110

Developmental screening with scoring and documentation, per standardized instrument

Table 4 - Fluoride varnishmixedCovered

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

Table 5 - Prenatal pediatrician E/M codes (partial)CPTCovered

99201	Office/outpatient visit for evaluation and management of a new patient (~10 minutes)
99202	Office/outpatient visit for new patient (~20 minutes)
99203	Office/outpatient visit for new patient (~30 minutes)

Table 6 - Newborn services (partial)CPTCovered

99184	Initiation of selective head or total body hypothermia in critically ill neonate
99460	Initial hospital/birthing center care for evaluation/management of normal newborn infant
99461	Initial care for normal newborn infant seen in other than hospital/birthing center
99462	Subsequent hospital care for normal newborn infant
99463	Initial hospital/birthing center care for newborn admitted & discharged same date

Table 7 - Miscellaneous physician services (partial)CPTCovered

11719	Nail procedure (code listed in Table 7)
36415	Collection of venous blood by venipuncture
95249	Ambulatory continuous glucose monitoring, patient-provided equipment, >=72 hours
95250	Ambulatory continuous glucose monitoring, office-provided equipment, >=72 hours
95251	Ambulatory continuous glucose monitoring analysis, interpretation and report

Subsequent hospital/observation careCPTCovered

99231	Subsequent hospital care, problem focused history/exam, straightforward or low complexity MDM
99232	Subsequent hospital care, expanded problem focused history/exam, moderate complexity MDM
99233	Subsequent hospital care, detailed history/exam, high complexity MDM; ~25-35 minutes

Observation/admission and discharge; discharge managementCPTCovered

99234	Observation/inpatient admission and discharge same date; detailed/comprehensive components; straightforward/low complexity; ~40 minutes
99235	Observation/inpatient admission and discharge same date; comprehensive components; moderate complexity; ~50 minutes
99236	Observation/inpatient admission and discharge same date; comprehensive components; high complexity; ~55 minutes
99238	Hospital discharge management; 30 minutes or less
99239	Hospital discharge management; more than 30 minutes

Emergency department and critical careCPTCovered

99281	ED visit; problem focused history/exam; straightforward MDM; self-limited or minor
99282	ED visit; expanded problem focused; low complexity MDM; low-moderate severity
99283	ED visit; expanded problem focused; moderate complexity MDM; moderate severity
99284	ED visit; detailed history/exam; moderate complexity MDM; high severity
99285	ED visit; comprehensive exam; high complexity MDM; imminent threat to life/function
99291	Critical care, first 30-74 minutes
99292	Critical care, each additional 30 minutes

Domiciliary and home visit — new patient codesCPTCovered

99324	Domiciliary/rest home visit, new patient; problem focused; ~20 minutes
99325	Domiciliary/rest home visit, new patient; expanded problem focused; ~30 minutes
99326	Domiciliary/rest home visit, new patient; detailed history/exam; ~45 minutes
99327	Domiciliary/rest home visit, new patient; comprehensive; ~60 minutes
99328	Domiciliary/rest home visit, new patient; comprehensive/high complexity; ~75 minutes
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

Home visit — established patient codesCPTCovered

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; moderate complexity
99350	Home visit, established patient; comprehensive; ~60 minutes

Prolonged servicesCPTCovered

99354	Prolonged E/M or psychotherapy service in office/outpatient; first hour
99355	Prolonged E/M or psychotherapy service in office/outpatient; each additional 30 minutes
99356	Prolonged service inpatient/observation; first hour
99357	Prolonged service inpatient/observation; each additional 30 minutes
99358	Prolonged E/M before/after direct patient care; first hour
99359	Prolonged E/M before/after direct patient care; each additional 30 minutes

Team conferences and supervision codesCPTCovered

99367	Medical team conference with interdisciplinary team, patient/family not present; physician; 30+ minutes
99368	Medical team conference with interdisciplinary team, nonphysician; 30+ minutes
99374	Supervision of patient under home health agency (patient not present), 15-29 minutes/month
99375	Supervision of patient under home health agency (patient not present), 30+ minutes/month
99377	Supervision of hospice patient (patient not present), 15-29 minutes/month
99379	Supervision of nursing facility patient (patient not present), 15-29 minutes/month
99380	Supervision of nursing facility patient (patient not present), 30+ minutes/month

Preventive medicine and counseling codesCPTCovered

99386	Initial comprehensive preventive visit, new patient; 40-64 years
99387	Initial comprehensive preventive visit, new patient; 65+ years
99396	Periodic comprehensive preventive visit, established patient; 40-64 years
99397	Periodic comprehensive preventive visit, established patient; 65+ years
99401	Preventive medicine counseling ~15 minutes
99402	Preventive medicine counseling ~30 minutes
99403	Preventive medicine counseling ~45 minutes
99404	Preventive medicine counseling ~60 minutes

Behavioral, prolonged staff services, interprofessional and remote monitoringCPTCovered

99406	Smoking cessation counseling; intermediate (>3 to 10 minutes)
99407	Smoking cessation counseling; intensive (>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	Group preventive counseling; ~30 minutes
99412	Group preventive counseling; ~60 minutes
99415	Prolonged clinical staff service during E/M in office; first hour
99416	Prolonged clinical staff service during E/M in office; each additional 30 minutes
99451	Interprofessional telephone/Internet/EHR assessment with written report; 5+ minutes
99452	Interprofessional referral service by treating/requesting physician; 30 minutes

1–10 of 14

1/2

Neonatal and pediatric critical care/intensive care codesCPTCovered

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

1–10 of 12

1/2

Cognitive impairment assessment and care planningCPTCovered

99483

Assessment and care planning for cognitive impairment/dementia with required elements (cognition-focused evaluation, MDM moderate/high, functional assessment, standardized instruments, medication reconciliation, neuropsychiatric evaluation, safety evaluation, caregiver assessment, advance care plan, written care plan)

Selected CPT codes and descriptionsCPTCovered

99466	Critical care face-to-face services during interfacility transport, pediatric; first 30-74 minutes
99467	Critical care face-to-face services during interfacility transport, pediatric; each additional 30 minutes
99468	Initial inpatient neonatal critical care, evaluation and management of critically ill neonate (≤28 days)
99469	Subsequent inpatient neonatal critical care, per day
99471	Initial inpatient pediatric critical care for 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, ages 2–5 years
99476	Subsequent inpatient pediatric critical care, ages 2–5 years
99483	Assessment and care planning for cognitive impairment with specified required elements
99484	Care management services for behavioral health conditions, ≥20 minutes clinical staff time/month

1–10 of 13

1/2

Selected G-codes and other HCPCS entriesHCPCSCovered

G0245	Initial physician E/M of diabetic patient with LOPS including exam elements and education
G0246	Follow-up E/M of diabetic patient with LOPS including specified exam elements
G0247	Routine foot care for diabetic patient with LOPS including local wound care, debridement
G0438	Annual wellness visit; initial
G0439	Annual wellness visit; subsequent
G0442	Annual alcohol misuse screening, 15 minutes
G0443	Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
G0444	Annual depression screening, 15 minutes
G0463	Hospital outpatient clinic visit for assessment and management
G0511	RHC/FQHC general care management; 20 minutes+ clinical staff time/month

1–10 of 11

1/2

Critical care/transport minimum time

Minimum billable time30 minutes (critical care and pediatric critical care transport require >=30 minutes before critical care codes apply)

Services <30 minutesShould be billed with the appropriate E&M code (not critical care)

Provider Responsibilities, Documentation and Billing Requirements

Prior Authorization

Medical necessity and prior authorization

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

Medical necessity sources: LCD, NCD, InterQual, EOHHS, CMP
Providers must verify eligibility, coverage and prior authorization before services
Contact Provider Services: 1-800-963-1001

Prior Authorization

Prior authorization for additional screening services

Certain additional screening services require prior authorization or are subject to limits. Providers must obtain authorization when plan limits are exceeded or when the services are beyond EPSDT or routine coverage limits.

Pediatric Autism Screening: members age 3–21 — commercial and Medicaid limits apply; additional services require prior authorization when limits exceeded

Definitions and Required Elements

Care Plan Oversight (CPO)

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

Scope of servicesIncludes oversight for complex or multidisciplinary care requiring ongoing physician involvement

Related activitiesTime spent reviewing patient status reports and participating in care conferences and medical therapy adjustments

Critical care

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

Components not separately reimbursableListed procedures (e.g., arterial puncture, intubation, ventilator management) are part of critical care and not billed separately

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysician Services Reimbursement and Billing Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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

SourceLink

On This Page

Exclusions (examples)

Telephone E&M services billed by the same provider or provider group on the same date of service as an office/E&M visit are excluded.
Consultation services (99241-99245, 99251-99255, G0425-G0427) are excluded.
Chronic Care Management services are excluded for Medicaid and Commercial members (per exclusions list).

Providers must submit complete claims within contractual timeliness; Neighborhood may request medical records to support billed services and medical necessity and reserves the right to audit.

Non-reimbursable separate components

Listed critical care components (e.g., arterial puncture, intubation, ventilator management) are not separately reimbursable

Prolonged services minimum billable time

Minimum billable duration30 minutes (prolonged services are time-based and services under 30 minutes are not billable)

Billing unitsProlonged services billed in first hour and additional 30-minute increments per CPT (e.g., 99354–99359)

DocumentationPatient chart should clearly indicate time spent face-to-face or without direct patient contact; notes may be requested

Pediatric fluoride varnish limit

Annual limitFour (4) units per plan year for Commercial members; four (4) units per year rolling for Medicaid

Allowed codes99188 (physician application) and D1206 (topical fluoride varnish) listed in Table 4

Required diagnosisZ29.3 must be used for fluoride varnish claims

Care Plan Oversight limit

Monthly limitCare Plan Oversight (CPO) limited to one (1) unit per month

DefinitionPhysician supervision of patients under home health, hospice, or nursing facility care involving review of reports, participation in care conferences, and development/revision of care plans

Typical activitiesReview of patient status reports, participation in care conferences, and medical therapy adjustments

Typical time thresholds

Common time multiplesTypical code times include 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, and 75 minutes

Hourly structureSome codes specify first hour and additional 30-minute increments (e.g., prolonged services, care management increments)

Setting-specific examplesSubsequent hospital/observation codes commonly list 15–55 minute typical times depending on complexity (e.g., 99231 ~15 min; 99233 ~25–35 min)

Minimum monthly clinical staff time for CCM

Minimum clinical staff time (CCM)20 minutes per calendar month directed by a physician or qualified health care professional for CPT 99490

Complex CCM99487 requires 60 minutes of clinical staff time per calendar month (moderate/high complexity MDM and comprehensive care plan)

Additional incrementsAdditional clinical staff time may be reported with 99489 or G2058 for each additional 20–30 minute increment

Transitional care follow-up window

Initial contact timeframeDirect contact (telephone, electronic or face-to-face) with patient/caregiver within 2 business days of discharge for transitional care management codes

Face-to-face follow-up windowsFace-to-face visit within 7 calendar days for 99496 (high complexity) or within 14 calendar days for 99495 (moderate complexity)

MDM requirementTransitional care requires specified level of medical decision making during the service period (moderate for 99495; high for 99496)

Pediatric Developmental Screening: commercial and Medicaid limits apply; additional services require prior authorization when limits exceeded

Pediatric Fluoride Varnish: age 6 months to 18.99 years — commercial and Medicaid unit limits apply; additional units beyond limits require prior authorization

Billing Rule

Pediatric Autism Screening billing requirement

Pediatric autism screening services must be billed with an appropriate diagnosis (for example Z00.121) and with the codes listed in the pediatric screening code table; when required by the policy, add modifier U1. Ensure documentation supports medical necessity and frequency limits; obtain prior authorization for services beyond plan-specified limits.

Required diagnosis example: Z00.121
Use the pediatric screening code table and add modifier U1 when specified
Obtain prior authorization for services beyond plan limits

Billing Rule

Pediatric Fluoride Varnish billing requirement

Pediatric fluoride varnish must be billed with diagnosis code Z29.3 and the appropriate procedure code from the referenced table. Follow age and unit limits: covered for members age 6 months to 18.99 years; commercial limited to four units per plan year; Medicaid limited to four units per year (rolling). Obtain authorization for additional services beyond these limits.

Required diagnosis: Z29.3
Age: 6 months to 18.99 years
Commercial: limited to 4 units/plan year; Medicaid: limited to 4 units/rolling year
Prior authorization required for additional units

Billing Rule

Newborn Services billing requirement

Newborn services must be billed with an appropriate newborn diagnosis (Z38.00–Z38.8) and the procedure codes listed in the newborn services table (Table 6). Documentation must support the billed code and medical necessity.

Required diagnosis range: Z38.00 to Z38.8
Use codes from Table 6 (e.g., 99460–99465, 99463–99465, 99184 as applicable)
Ensure medical record documentation supports the service billed

Billing Rule

E/M code listing — hospital/observation

Hospital and observation E/M codes must be used as appropriate for inpatient, observation, and newborn care. Use only one E/M code per practice per specialty per date of service unless documentation supports separate services (for example, modifier 25 for a sick visit on the same day as a preventive visit when additional work is documented).

Examples of hospital/observation E/M codes included in policy: 99231–99233 (subsequent hospital care), 99226 (subsequent observation care), newborn-specific codes in Table 6
Only one E/M code reimbursed per practice per specialty per date of service unless documentation supports separate service
When billing both preventive and sick visits on same day, apply modifier 25 to the sick visit and retain supporting documentation

Billing Rule

Domiciliary and home visit E/M codes

Domiciliary, rest home, and home visit E/M codes should be billed using the appropriate domiciliary/home visit codes (for new and established patients) as described in the policy. Ensure documentation supports level of service and complexity.

Common domiciliary/home visit codes referenced: 99324–99328 (new patient), 99334–99337 (established patient)
Use appropriate code that reflects history, exam, and medical decision making documented
Documentation must support time and complexity when applicable

Billing Rule

Prolonged and supervision services

Prolonged services and supervision/professional time beyond typical service duration must be billed with the appropriate prolonged service codes. Include documentation of time and the reason prolonged services were required.

Office/outpatient prolonged codes: 99354 (first hour) and 99355 (each additional 30 minutes)
Inpatient/observation prolonged codes: 99356 (first hour) and 99357 (each additional 30 minutes)
Document total time, services rendered beyond typical duration, and medical necessity for prolonged billing

Billing Rule

Remote monitoring and interprofessional services

Remote physiologic monitoring and related interprofessional/telehealth services must be billed using the specified RPM and telehealth codes. Ensure device supply, monitoring intervals, time spent, and interactive communications are documented as required by the CPT definitions.

Remote monitoring supply code example: 99454 (device supply with daily recordings, each 30 days)
Remote monitoring treatment management: 99457 (first 20 minutes/month) and 99458 (additional minutes)
Document device details, monitoring period, time spent on management, and interactive communications

Documentation Required

Cognitive assessment (99483)

Cognitive assessment and care planning (CPT 99483) requires the full set of elements defined by CPT: cognition-focused evaluation including history and exam, moderate/high complexity medical decision making, functional assessment, use of standardized instruments, medication reconciliation, evaluation for neuropsychiatric symptoms, safety evaluation, identification and assessment of caregivers, and creation of a written care plan with caregiver education and resource referral. Documentation must include all required elements to support billing.

CPT 99483 required elements: cognition-focused evaluation, standardized instruments (e.g., FAST, CDR), functional assessment, medication reconciliation, neuropsychiatric screening, safety evaluation, caregiver assessment, written care plan
Ensure documentation clearly demonstrates each required element and medical necessity

Documentation Required

Documentation & claims submission

Providers must submit complete and timely claims in accordance with contract and national claim standards. Documentation must support billed services and medical necessity; Neighborhood reserves the right to request medical records and to audit billed services. Coding must follow CPT, ICD‑10‑CM, and HCPCS guidelines.

Submit claims within contractual timely filing limits
Adjustments/corrections must include required forms and follow standards
Neighborhood may request medical records to support billed services and medical necessity

Transport specificsCritical care face-to-face during interfacility pediatric transport reimbursed when >30 minutes; services <30 minutes billed as E&M

Chronic Care Management (CCM)

DefinitionChronic Care Management (CCM) provides care coordination outside regular visits for patients with two or more chronic conditions expected to last >=12 months and place the patient at significant risk

Minimum monthly time99490 requires at least 20 minutes of clinical staff time per calendar month; only one practitioner may bill CCM per patient per month

Complex CCM99487 requires 60 minutes of clinical staff time per month with moderate or high complexity MDM and establishment/revision of a comprehensive care plan

Modifier 25

PurposeModifier 25 indicates a significant, separately identifiable E&M service on the same day as a preventive visit

Reimbursement conditionNeighborhood will reimburse a preventive visit and a sick visit when modifier 25 is applied and documentation supports both services

DocumentationMedical record must support that a significant abnormality or additional work was required for the sick visit

Modifier 24

PurposeModifier 24 indicates an unrelated evaluation and management service during the postoperative period

Reimbursement conditionPost-surgical visits unrelated to the surgery may be considered for separate reimbursement when billed with modifier 24 and supporting notes

ExclusionPost-surgical visits related to the surgery performed by the same physician are considered inclusive in the surgical package and are not separately reimbursable

Developmental screening (96110)

DefinitionDevelopmental screening (CPT 96110) is a standardized instrument-based developmental milestone or speech/language delay screen with scoring and documentation

Billing requirementPediatric developmental screening must be billed with diagnosis Z00.121 and code 96110 per Table 3

DocumentationScoring and documentation per standardized instrument are required

Fluoride varnish (99188 / D1206)

DefinitionFluoride varnish (99188 / D1206) is the application of topical fluoride varnish by a physician or qualified health care professional

Allowed codes99188 and D1206 are listed in Table 4 for topical fluoride varnish applications

LimitPediatric fluoride varnish limited to four (4) units per year (Commercial and Medicaid)

Newborn services (99460-99465, etc.)

Covered servicesNewborn services include initial and subsequent newborn E/M codes (e.g., 99460–99465) and related codes in Table 6

Required diagnosisMust be billed with a birth status diagnosis in the range Z38.00–Z38.8

Representative codesExamples in Table 6 include 99184, 99460, 99461, 99462, 99463, 99464, 99465

Medical decision making (MDM)

DefinitionMedical decision making (MDM) refers to the complexity of establishing diagnosis and management options (straightforward, low, moderate, high) used as a required component for E/M code selection

Usage examplesMDM level is paired with history and exam components to determine appropriate hospital/ED/subsequent care E/M codes (e.g., 99231–99233; 99281–99285)

Impact on timeTypical times vary by MDM and code (e.g., 99231 ~15 min; 99233 ~25–35 min; 99235 ~50 min)

Cognitive impairment assessment (99483) required elements

Required elementsCPT 99483 requires cognition-focused evaluation, moderate/high complexity MDM, functional assessment, use of standardized instruments (e.g., FAST, CDR), medication reconciliation, evaluation for neuropsychiatric symptoms, safety evaluation, caregiver assessment, advance care planning, and a written care plan

SettingsCan be performed in office/other outpatient, home, or domiciliary/rest home settings

DocumentationAll required elements must be documented; an independent historian may be required

Assessment of and care planning for a patient with cognitive impairment

ScopeAssessment of and care planning for cognitive impairment includes a cognition-focused evaluation, MDM of moderate/high complexity, functional assessment, standardized instrument use, medication reconciliation, caregiver assessment, and written care plan

Code99483 is the designated CPT code for assessment and care planning for cognitive impairment/dementia

Settings and documentationCan be performed in office, home, or domiciliary settings; documentation must include all required elements (may need independent historian)

Care management services requiring specified minimum monthly clinical staff time and comprehensive care plan

CCM minimum time requirements99490 requires at least 20 minutes of clinical staff time per calendar month; 99487 requires 60 minutes for complex CCM; 99491 requires 30 minutes personally provided by physician

Comprehensive care planCCM services require establishment, implementation, revision, or monitoring of a comprehensive care plan

Additional reportingAdditional clinical staff time may be reported using 99489 (add-on) or G2058 (additional 20-minute increments) where applicable