CurrentUniversity Health Alliance (HSA)Policy MPP-0013-120101
Evaluation and Management (E/M) office visits and consultations reimbursement
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Defines University Health Alliance (UHA) reimbursement policy for office visits, consultations, and related Evaluation and Management (E/M) services, including documentation, medical necessity, APP billing, and limitations affecting providers submitting claims to UHA.
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyEvaluation and Management (E/M) office visits and consultations reimbursement
Policy CodePolicy MPP-0013-120101
Change TypeNo material change
Effective DateApr 22, 2024
Last ReviewApr 22, 2024
Next Review Date
Key ActionUHA may request medical records and perform retrospective review; ensure documentation is contemporaneous and supports medical necessity.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
3 yearslook-back period (new vs established)
99211-99215established patient E/M codes
Modifier 25modifier required for separate E/M payment
G2211/Rev0510not separately reimbursed
04/22/2024effective date
E/M Reimbursement Criteria
E/M Reimbursement Criteria
Covered when ALL of the following documentation and medical‑necessity requirements are met:
Medical necessity: Service must meet the Hawaii Revised Statute definition of medical necessity and be supported by evidence‑based criteria (e.g., Milliman Guidelines, specialty directives). Only information pertinent to the billed service will be considered; over‑documentation, inauthentic data, or copied/ cloned documentation without contemporaneous verification will not be reimbursed.
Documentation standards: Records must support the level of service per current AMA/CPT and CMS guidelines, be contemporaneous or completed as soon as practicable, legible, and include rationale for labs, tests, procedures, or unusually frequent follow‑up. Documentation created more than one week after the service is rarely acceptable and requires valid justification.
Patient status determination: New vs established patient is determined using a 3‑year look‑back. A patient not seen by the physician (or another physician of the same specialty in the same group/clinic) within the past three years is a new patient; otherwise the patient is established. Coverage rules treat covering physicians in the same practice as established patient visits.
Consultation criteria: Office consultations must be requested by another physician, the consulting physician must provide a report to the requesting physician and memorialize transfer of information. Services that are not considered office consultations (eg, predetermined transfers/referrals, self‑referrals, follow‑up consultations [report as established patient visit CPT 99211‑99215], telephone, anesthesia, radiological/pathological consultations, or consultations within same specialty) should be billed appropriately as indicated.
APP billing and scope: Advanced Practice Providers (APPs) may bill independently when appropriate and within scope of practice. Onsite physician supervision, shared‑visit, or incident‑to oversight may be required for certain initial evaluations or complex services; UHA may deny payment if APPs bill outside their scope.
Separate payment limitations: E/M services performed with a diagnostic or therapeutic procedure are not separately paid unless modifier 25 is appropriately applied to indicate a separate, significant E/M service beyond usual pre‑/post‑procedure care. Rev code 0510 and HCPCS code G2211 are not separately reimbursed when billed with an E/M; these are paid under the professional fee schedule. Digital rectal exam (G0102) is not separately reimbursed when performed with a comprehensive or preventive service.
Administrative and retrospective review: UHA may perform retrospective review and request medical records or consultation reports to validate billed services; illegible records or failure to provide requested documentation may result in denial and potential recoupment.
Relevant Codes and Documentation Rules
Documentation timeliness
Timeliness requirementDocumentation must be contemporaneous with the service or completed as soon as practicable after the service is provided.
Late documentation thresholdDocumentation after one week of the date of service is rarely acceptable and would require valid reasoning if requested by UHA.
Exception allowancePotential exceptions may include documentation accurately supplemented and prompted by hand-rendered images or photographs created at the time of service.
Prior Authorization, Reviews, and Billing Actions
Prior Authorization
Prior Authorization is Advisory; UHA May Retrospectively Review and Recoup
This UHA payment policy is a guide to coverage and to the need for prior authorization; it is not a guarantee of payment and contract terms or individual member plans may apply. UHA also reserves the right to perform retrospective review to validate whether services met payment determination criteria and may request supporting documentation or recode services if necessary.
- Policy is a guide — not instruction in practice and not a guarantee of payment; contract terms and member plans may affect payment.
- UHA may request supporting documentation and reconsider medical necessity with submitted evidence.
- UHA reserves the right to perform retrospective review and to re‑code visits or deny payment if documentation does not support billed services.
Definitions and Billing Roles
New patient
DefinitionA patient who has not been seen by the physician, or by a physician of the same specialty in the same group/clinic, within the past three years.
Group practice ruleFor physicians in a group or clinic, the patient is new if not seen by another physician of the same specialty in that group/clinic within the past three years.
Implication for billingServices that are not consultations (eg, referrals) should be billed as new patient visits when the new‑patient criteria apply.
Established patient
DefinitionA patient whose medical history is familiar to the physician and who has been treated by the physician within three years of the visit.
Covering physician ruleWhen a physician is covering for another physician in the same practice or clinic, the visit is not considered new and is paid as an established patient visit.
Location change noteA change in the physician's practice location does not reset status; if the physician treated the patient within the past three years, the patient remains established.
Office consultation
DefinitionAn office consultation is a service by a physician whose opinion or advice regarding a specific problem is sought by another physician; the requesting physician generally continues to manage the patient's care.
Reporting requirementThe consulting physician's report must be forwarded to the requesting physician and the transfer of information must be memorialized.
Not considered consultationsPredetermined transfers, self-referrals, follow-up consultations (report as established patient visits CPT 99211-99215), telephone, anesthesia, radiological/pathological consultations, and consultations within the same specialty are not office consultations.
Advanced Practice Provider (APP) billing
Independent billingAdvanced Practice Providers (APPs) may bill independently for services.
Supervision/oversightImmediate onsite physician supervision or shared-visit/incident-to oversight may be required for initial evaluation and/or diagnostic testing of conditions beyond APP training or specialty certification.
Scope and documentationAPPs must practice within their usual scope, training, specialty education or certification and clinical encounters where the APP is the primary provider and author of documentation should be billed under the APP, not the supervising physician.
Cloned documentation
DefinitionCloned documentation: entries in the medical record that are worded exactly alike across visits or patients, lacking individualized detail.
Medical necessity impactCloned documentation does not meet medical necessity requirements due to lack of specific, individual information.
Payment riskIdentification of cloned documentation will lead to denial of services for lack of medical necessity and possible recoupment of overpayments.
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyEvaluation and Management (E/M) office visits and consultations reimbursement
Policy CodePolicy MPP-0013-120101
Change TypeNo material change
Effective DateApr 22, 2024
Last ReviewApr 22, 2024
Next Review Date
Key ActionUHA may request medical records and perform retrospective review; ensure documentation is contemporaneous and supports medical necessity.
SourceLink
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