Evaluation and Management FAQs

Below are key questions and answers in regards to evaluation and management services in rheumatology practices.

If a patient was previously seen by my partner and is now seeing me for the first time, can I bill for a new patient visit?

If the partner is of the same specialty and has treated the patient within a three year time period; then no, the visit will have to be coded as an established patient visit. According to the 2015 CPT™, “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health professional of the exact same specialty or subspecialty who belongs to the same group practice, within the past three years”.

Can I bill for a procedure and an evaluation and management visit that was performed on the same day?

Yes, as long as the reason for the evaluation and management visit was done for a separate and/or significant reason from the procedure. For example: A patient is scheduled to see the physician for a follow-up visit for their OA, upon evaluation,  the physician decides the patient’s knee needs to be aspirated – this is billable as a separate procedure and should be billed with the modifier -25 on the E&M visit.  Example of when a procedure is not billable on the same day as an E&M: A patient is in the office for their second injection of a series of three knee injections – because the patient is scheduled for their injection. Unless a separate issue has developed and the patient will need to be evaluated, then an office visit is billable with this procedure.

A patient is on a DMARD and a biologic; doesn’t this make an E/M visit automatically a level four visit?

No, the E&M levels are not based on the diagnosis but are determined by the work that is performed on that date of service. An E&M visit is comprised of a chief complaint, history, examination and medical decision making.

Can the nursing visit 99211 be billed for phone calls?

No, nursing visits can only be billed if the service being done is face-to-face with the patient and is typically at a minimum of five minutes.

Can we still bill for consultation codes?

Consultation codes 99241-99242(office consultation) and 99251-99255 (inpatient consultation) are not billable to CMS since 2010. There are some, although few, private carriers that still allow for the billing of consultation codes. Your practice will have to verify if the carrier will allow for the billing of consultation codes.

If a consultation code cannot be billed, what codes should be billed to identify the level of service performed?

If it is an E&M service for a  new patient then CPT™ codes 99201-99205 can be billed. For established patients, CPT™ codes 99212-99215 should be used based on level of service. If the service is for an inpatient initial patient visit, the initial hospital care codes 99211-99223 can be billed by more than one physician, as long as no other physician of the same specialty or subspecialty has billed for a visit on the same date of service.

Can time be used to determine a level of an E/M visit?

Yes, but please not that specific documentation requirement must be met in order to use time as the key factor in determining the level of an E&M visit. There must be documentation of the length of the visit, and it must be more than 50% of the visit that was spent face-to-face with the patient counseling and/or coordinating care, it is also required to document what was discussed during the counseling and/or coordination of care.