Coding Guidelines for E&M Services

• A provider may report only one ‘new patient’ code on a single date of service.
• A provider may report only one code from a range of codes describing an initial E&M service on a single date of service.
• A provider may report only one ‘per diem’ E&M service from a range of per diem codes on a single date of service.
• A provider shall not report an ‘initial’ per diem E&M service with the same type of ‘subsequent’ per diem service on the same date of service.
• A provider shall not double count time if reporting more than one E&M service for the same date of service or same monthly period.
• E&M codes describing observation/inpatient care services with admission and discharge on same date (CPT codes 99234-99236) shall not be reported on the same date of service as initial hospital care per diem codes (99221-99223), subsequent hospital care per diem codes (99231-99233), or hospital discharge day management codes (99238-99239).
• The prolonged service with direct face-to-face patient contact E&M codes (CPT codes 99354- 99357) may be reported in conjunction with some E&M codes.
• Since critical care (CPT codes 99291-99292) and prolonged E&M services (CPT codes 99354- 99357) are reported based on time, providers/suppliers shall not include the time devoted to performing separately reportable services when determining the amount of critical care or prolonged provider E&M service time.
• E&M services, in general, are cognitive services, and significant procedural services are not included in E&M services. Certain procedural services that arise directly from the E&M service are included as part of the E&M service. For example, cleansing of traumatic lesions, closure of lacerations with adhesive strips, application of dressings, counseling and educational services are included in E&M services.
• Because of the intensive nature of caring for critically ill patients, certain practitioner services in addition to patient history, examination, and medical decision making are included in the evaluation and management associated with critical and intensive care.
• Services not separately reportable by practitioners reporting critical care CPT codes 99291 and 99292 include, but are not limited to, the interpretation of cardiac output measurements (CPT codes 93561 and 93562), chest X-rays (CPT codes 71045 and 71046), blood gases, and data stored in computers (ECGs, blood pressures, hematologic data), gastric intubation (CPT codes 43752, 43753), temporary transcutaneous monitoring (CPT code 92953), ventilator management (CPT codes 94002-94004, 94660, 94662), and vascular access procedures (CPT codes 36000, 36410, 36600). However, facilities may separately report these services with critical care CPT codes 99291 and 99292.
• Practitioner inpatient neonatal and pediatric critical and intensive care services (i.e., CPT codes 99468-99480) include the same services included in critical care CPT codes 99291 and 99292. These services shall not be reported separately by practitioners reporting CPT codes 99468-99480. However, facilities may separately report these services with CPT codes 99468-99480.
• If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M service is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with the appropriate modifier. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.
• If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedures do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.
• For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery. Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24 (‘Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period’).
• CPT codes 99238 and 99239 describe hospital discharge day management. These codes shall not be reported with initial hospital care (CPT codes 99221-99223) or initial observation care (CPT codes 99218-99220) for the same date of service. If a physician provides initial hospital care or observation care on the same day as discharge, the services shall be reported with CPT codes 99234-99236 (Observation or inpatient hospital care with admission and discharge on the same date of service). Additionally, CPT codes 99238 and 99239 include all physician services provided to the patient on the date of discharge. The provider shall not report another E&M CPT code (e.g., 99202-99215, 99281-99285) on the same date of service that the provider reports CPT code 99238 or 99239.

CPT Copyright 2022: American Medical Association

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle management services. We shared coding guidelines for E&M services so that providers will get accurately reimbursed for delivered services. We referred various source materials along with the Medicare coding manual to discuss medical billing for cardioversion in detail. If you need any assistance in medical billing and coding for your practice, email us at: [email protected] or call us at: 888-357-3226.

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