CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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

Defines coding, documentation, and payment rules for Evaluation and Management services (office, observation, inpatient, and prolonged services) for providers submitting claims to 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 ActionWhen preventive and sick visit E/M are billed the same day, include required documentation and an appropriate modifier to support separate payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one per practice/specialty/datelimit on E/M payment

>=8 hrsobservation minimum

99354-99359prolonged codes allowed

>=30 minprolonged minimum time

E/M Coverage Criteria by Setting

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E/M coverage criteria by setting

Covered when the following setting-specific Evaluation & Management (E/M) billing rules are met:

ALL of the following

- ALL of the following
  - Payment is allowed for only one E/M code per practice, per specialty type, per date of service
    Applies to both new and established patients
  - If a preventive exam and a sick visit E/M are billed on the same day, documentation may be requested and a modifier indicating a separate service is required
  - 'New patient' is defined as 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 years
- ALL of the following
  - Payment is allowed for only one E/M code per practice, per specialty type, per date of service
  - Applies to new and established patients admitted to a hospital specifically for observation (area need not be a designated observation unit)
  - Only the physician who admits the patient to observation status may report the initial observation E/M code
    Any other physician should bill appropriate outpatient/office or consultation codes for services provided while patient is on observation
  - Services performed on the same date of service by the same provider are considered part of the initial observation care
  - ALL of the following
    When patient is admitted and discharged from observation status on the same date, codes 99234-99236 apply (Observation or Inpatient Care Services, including admission and discharge)
- ALL of the following
  - Payment is allowed for only one E/M code per practice, per specialty type, per date of service
  - Initial E/M services apply to new or established patients admitted to an inpatient hospital or partial hospital setting
  - When patient is admitted and discharged from inpatient status on the same date, codes 99234-99236 (Observation or Inpatient Care Services including admission and discharge) apply
  - When admitted and discharged on same day, only the initial hospital care code should be reported by the admitting provider; this includes any prior observation services on the same day by the admitting provider
  - Subsequent services are services rendered outside of the initial admitting date
- ALL of the following
  - Prolonged service codes (99354-99359) with or without face-to-face contact may be reimbursed
  - Prolonged services are billed in addition to a base E/M code and are time-based
  - Prolonged services less than 30 minutes in duration are not billable and should not be reported
  - Prolonged service time need not be continuous
  - Only one prolonged care code can be billed per day by the same physician or qualified health professional
  - Patient chart must clearly indicate time spent (face-to-face or without direct patient contact)

Settings summary

One E/M per practice/specialty/date applies across office, observation, and inpatient settings
99234-99236 applied for same-day admit/discharge when observation >=8 and <24 hours and billing physician documents admit/discharge
Prolonged codes 99354-99359 reimbursable when >=30 minutes and only one prolonged code per day

CPT/Observation/Prolonged Service Coding

Same-day admission/discharge observation/inpatient codesCPTCovered

99234-99236

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

Prolonged service codesCPTCovered

99354-99359

Prolonged services (with and without face-to-face contact)

inv-04: Observation minimum duration

Observation minimum duration>= 8 hours and < 24 hours for codes 99234-99236

Physician presence requirementBilling physician must be present and personally providing the services during the observation stay

Admit/discharge documentationAdmitting and discharge notes must be written by the billing physician when using 99234-99236

inv-05: Prolonged minimum billable duration

Minimum billable prolonged time>= 30 minutes

Prolonged codesProlonged services (codes 99354-99359) may be reimbursed with or without face-to-face contact

Documentation of timePatient chart must clearly indicate time spent face-to-face or without direct patient contact; time need not be continuous

Documentation and Billing Actions for Providers

Documentation Required

Same-day preventive and sick visit billing

Payment is allowed for only one Evaluation and Management (E/M) code per practice, per specialty type, per date of service. If a preventive (well) exam and an E/M code for a sick visit are billed on the same day, providers must include documentation and an appropriate modifier to indicate the services are separate; clinical notes may be requested to substantiate separate payment.

Affected codes: E/M visit CPT codes and preventive visit codes
Modifier required to indicate separate service when both preventive and sick visit billed same day
Documentation: clinical notes substantiating separate and distinct services may be requested

Documentation Required

Prolonged services documentation

Prolonged services (CPT 99354-99359) with or without face-to-face contact may be reimbursed when billed in addition to a base E/M code. Prolonged services are time-based; services under 30 minutes are not billable and only one prolonged service code may be billed per day by the same clinician. Clinical notes documenting time (face-to-face or non-face-to-face), and which need not be continuous, may be requested to consider additional reimbursement.

Time-based reporting required; document total minutes
Applicable to CMS-1500 and UB-92 claim submissions and all places of service where E/M codes are used

Key Definitions

inv-08: New patient

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.

Applies toOffice and outpatient evaluation and management services where patient classification (new vs established) affects coding and payment

Documentation implicationProvider documentation should support that no services were provided by same specialty/subspecialty in same practice within prior three years

inv-09: Admitting physician (observation)

Admitting physician billing ruleInitial observation E/M code must be reported only by the physician who admits the patient to observation status.

Other providersAny physician other than the admitting physician should use appropriate outpatient/office or consultation codes for services provided while patient is on observation status.

ScopeApplies to patients admitted to hospital specifically for observation (designated area not required)