Covered when medically necessary and coded per CPT/ICD-10/HCPCS with the billing rules and inclusions/exclusions below.
Physician services include routine physical examinations, periodic check‑ups, sick visits, specialty office visits, observation care, inpatient care, and home visits (see policy statement).
Routine venipuncture (routine blood draw) is not separately reimbursable when billed with an E&M service code.
Critical care is defined as 30 minutes or more of direct physician care for a critically ill/injured patient; services less than 30 minutes should be billed with the appropriate E&M code.
Critical care components: Listed procedures (e.g., arterial puncture, ventilator management, IV fluid administration, lumbar puncture, endotracheal intubation, pulse oximetry, chest x‑ray interpretation, blood transfusion, etc.) are considered components of critical care and are not separately reimbursable.
Critical care transport (pediatric): Physician attendance/face‑to‑face during interfacility transport of a critically ill/injured child <24 months is reimbursed if total time >30 minutes; services <30 minutes billed with appropriate E&M; specified transport components are not separately reimbursable.
Inpatient visit inclusion: Services provided on the same date of service by the same provider that are part of admission are considered part of initial inpatient care; same‑date admit/discharge codes 99234‑99236 apply.
Prolonged inpatient services: Prolonged services (99354‑99359) may be reimbursed as add‑ons to a base E&M code; they are time‑based, may be noncontinuous, services <30 minutes are not billable, and only one prolonged care code may be billed per day by the same physician or qualified health professional; documentation of time is required.
New patient visits: New patient office visits are reimbursed when the physician (or another physician of same specialty in the same group) has not seen the patient within the prior three years.
Newborn services: Hospital or birthing center newborn care is covered and reimbursable per CPT guidelines (see newborn services section).
Observation services: Only the physician who admits the patient to observation may report the initial observation E/M; observation stays must be at least 8 hours and less than 24 hours for the observation admission/discharge codes (99234‑99236) to apply; the billing physician must personally provide services and write admitting/discharge notes.
Osteopathic manipulative treatment: OMT (osteopathic manipulation) is covered and reimbursable according to CPT guidelines.
ANY of the following
Podiatric trimming/debridement of nails is covered for Medicaid and INTEGRITY with no diagnosis restrictions.
For Commercial lines, nail trimming/debridement is covered only for specified diabetic diagnosis codes (E08.00‑E09.9, E10.10‑E13.9).
Post‑surgical visits performed by the operating physician are included in the global surgical package and not separately reimbursable; unrelated post‑surgical visits may be considered for separate reimbursement with modifier 24 and supporting documentation.
Prenatal pediatric visits: Prenatal pediatric office visits are covered and reimbursable for two visits, up to 30 minutes per visit.