Currentpriority healthPolicy N/A

E/M SERVICES BILLED WITH TREATMENT ROOM REVENUE CODES

This policy governs reimbursement for facility evaluation and management (E/M) charges billed with treatment room revenue codes (0760, 0761, 0769) for outpatient hospital treatment room/specialty room services applicable to Priority Health claims.

Policy Summary

Payerpriority health

PolicyE/M SERVICES BILLED WITH TREATMENT ROOM REVENUE CODES

Policy CodePolicy N/A

Change TypeAdministrative / Reviewed

Effective DateNov 11, 2024

Next Review Date2026-02

Key ActionDo not bill facility E/M charges with treatment room revenue codes; treatment room services are reimbursed only when directly related to a same‑day procedure.

SourceLink

POLICY UPDATE CHANGES

Added 'Disclaimer' section.

Reviewed, no changes.

3treatment room revenue codes referenced

multipleE/M & procedure code ranges listed

2scheduled policy reviews

Coverage and Reimbursement Criteria

Reimbursement criteria

Covered when the following reimbursement criteria are met or not met:

Policy Summary

Payerpriority health

PolicyE/M SERVICES BILLED WITH TREATMENT ROOM REVENUE CODES

Policy CodePolicy N/A

Change TypeAdministrative / Reviewed

Effective DateNov 11, 2024

Next Review Date2026-02

Key ActionDo not bill facility E/M charges with treatment room revenue codes; treatment room services are reimbursed only when directly related to a same‑day procedure.

SourceLink

On This Page

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.

Facility evaluation and management (E/M) charges billed in conjunction with treatment room revenue codes 0760, 0761, 0769 are not reimbursed because these services do not represent a specific procedure performed in a treatment room.

Reimbursed when

Facility treatment room services are reimbursed when they are directly related to procedure(s) provided on the same day the treatment is rendered.

Billing treatment room revenue codes for office-based E/M services is considered incorrect coding and will not be reimbursed.

Ensure a valid procedure code accompanies a treatment room revenue code on the UB-04 for plan acceptance.

Revenue Codes and E/M Procedure Mapping

Revenue and E/M codesmixed

0760	Specialty Services General
0761	Treatment Room
0769	Other Specialty Services
99201-99215	Evaluation and Management Services
99221-99223	Evaluation and Management Services
99231-99233	Evaluation and Management Services
99238-99499	Evaluation and Management Services
G0380-G0384	Procedures and Professional Services
G0463	Procedures and Professional Services
G2212	Procedures and Professional Services

Reimbursable when tied to procedure same day

Policy ruleFacility treatment room services will be reimbursed only when they are directly related to procedure(s) provided on the same day the treatment is rendered.

Non‑reimbursable scenarioPriority Health does not reimburse facility E/M charges billed with treatment room revenue codes 0760, 0761, 0769 because they do not represent a specific procedure performed in a treatment room.

Incorrect coding guidanceBilling treatment room revenue codes for office‑based E/M services is considered incorrect coding and will not be reimbursed.

Billing Guidance and Provider Instructions

Billing Rule

Do not bill E/M with treatment room revenue codes; reimburse only if same-day procedure

Priority Health does not reimburse facility evaluation and management (E/M) charges billed in conjunction with treatment room revenue codes 0760, 0761, or 0769 because these charges do not represent a specific procedure performed in a treatment room. Facility treatment room revenue codes will be reimbursed only when the treatment room service is directly related to a procedure provided on the same day. Billing treatment room revenue codes for office-based E/M services is considered incorrect coding and will not be reimbursed.

Do not bill facility E/M charges with treatment room revenue codes 0760, 0761, 0769 — these are non-reimbursable unless tied to a same-day procedure.
Ensure a valid procedure performed the same day is documented and billed when submitting treatment room revenue codes for reimbursement.
Do not use treatment room revenue codes for office-based E/M services; such coding is incorrect and will be denied.

Definitions

Treatment room and specialty room services

DefinitionOutpatient services furnished on hospital premises that require use of a bed and periodic monitoring for a brief period to carry out minor procedures and allow recovery.

Use caseTreatment room use is expected for minor procedures and differs from major procedures that require an operating room.

SettingApplies to treatment room and specialty room outpatient services performed on hospital premises.

Evaluation and Management service

DefinitionServices reported by physicians and nonphysician practitioners; includes office and other outpatient E/M services.

Included settingsE/M services include office/outpatient, hospital inpatient, consultations, emergency room, nursing facility, domiciliary and home services.

Reportable byPhysicians and nonphysician practitioners report E/M services using applicable procedure codes.

Minor procedure

DefinitionMinor surgical procedures that are minimally invasive and performed over a brief period.

ExamplesBiopsies; repairs of cuts or small wounds; removal of warts, lesions, hemorrhoids or abscesses.

CharacteristicsMay be performed laparoscopically or arthroscopically with small incisions and specialized instruments; typically require brief recovery in a treatment room.

Revenue code

DefinitionA four‑digit code used on hospital bills to indicate patient location or the type of item/service received and that affects reimbursement.

PurposeInforms health plans where the patient was located when treatment was received or what item/service was provided.

Example linkageA valid procedure code must accompany a revenue code on billing forms for plan acceptance.

UB-04

FormUB‑04 forms are used by hospitals and other providers to bill institutional services.

Billing requirementA valid procedure code must accompany a revenue code for the UB‑04 to be accepted by the health plan.

Use caseUB‑04 is the standard institutional billing form for hospital charges and associated revenue codes.

OpenPayer

E/M SERVICES BILLED WITH TREATMENT ROOM REVENUE CODES

Coverage and Reimbursement Criteria

Revenue Codes and E/M Procedure Mapping

Billing Guidance and Provider Instructions

Definitions

Policy Changes and Review History