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Evaluation and Management (E&M) Services

Q.A patient was seen in our office during the day for hematuria. Patient was evaluated, treated and released from the office. Later that same evening, the patient contacted the urologist on call in acute pain. The patient was admitted to the hospital that same night. Can we bill for a separate evaluation and management service for the office and the hospital admission?

A. A separate office visit and admission code cannot be billed on the same day. Bill only for the hospital admission. However, the evaluation performed at the office visit earlier in the day can be added to the work of the admission service and the admission service can be billed at a higher service level if properly documented.

Q.How do you bill when a PA or NP performs an “incident to” service for a Medicare patient while there is a provider in the office suite?

A.The services should be billed under the supervising provider's NPI number for 100 percent reimbursement of the provider's fee schedule. When the ordering provider (the provider who originally saw the patient and outlined a treatment plan) is not the same as the supervising provider (the provider who was in the office the day of the visit), CMS clarified that it is acceptable for another provider in the same group to provide direct supervision and bill Medicare for the service when the ordering provider is not present in the office.

A nurse practitioner or a provider assistant can also serve as an ordering or supervising provider. However, payments for services provided will be limited by Medicare to 85 percent of the provider fee schedule. If you are billing under the nurse practitioner or provider assistants' NPI number, services provided by other medical staff can be billed incident to the NPP services.

When billing, make sure the proper provider’s name appears on the claim.

Further information on "incident to" billing requirements can be found at CMS 100-4, Transmittal 148 [pdf].

Q.We saw a patient several years ago and he recently came back for a visit to evaluate his prior medical condition. How do you distinguish a new patient from an established patient?

A.If a patient has not been seen (face-to-face contact) by any provider of the same specialty in your office for three years, that patient is a new patient.

Q.How do I bill for a “second opinion?”

A.A “second opinion” visit is generally performed as a request for a second or third opinion of a medical treatment or surgical procedure previously recommended by another provider.

In both the inpatient hospital setting and the nursing facility (NF) setting, a request for a second opinion would be made through the attending provider or provider of record. If this visit is requested of another provider or qualified NPP by the attending provider and meets the requirements for an Inpatient E&M then the appropriate Initial Inpatient E&M code should be reported by the consultant. In the office or other outpatient setting, report a request for a second opinion by a provider or qualified NPP, with the appropriate E&M (new or established) codes. If the second opinion is requested by the patient and/or family, report the E&M codes (99201-99205) for a new patient and established patient (99212-99215). A new patient is anyone who has not had a face-to-face encounter with any provider in the practice for more than three years.

Preoperative and Postoperative E&M Services

Q.A urologist performed a transurethral resection of the prostate (TURP). Ten days later, the patient was admitted to the hospital for chest pain. The family doctor asked the urologist to evaluate the patient's intermittent hematuriA. Is this considered a consultation?

A.Evaluation of a patient only 10 days postoperative with hematuria would not be considered a billable visit. Hematuria can be a normal occurrence of the original TURP. This visit should not be billed separately, as it is included within the global period of the TURP.

Q.Can you charge an admission code for a patient scheduled for a radical prostatectomy? Can you charge for a discharge visit?

A.You may not charge either admission or discharge. The CPT® global surgical package definition includes the following:

The admission and discharge are included in this global surgical package definition. 

Q.My urologist has a patient who has prostate cancer. The patient wants to go to a large teaching facility to have his prostatectomy performed. The patient will come back to our office for post-op follow up. How can we get reimbursed for the follow up? Isn't this included in the surgery?

A.Generally, if a surgeon performs the preoperative, surgery and postoperative care, the surgical CPT® code would be billed globally and no modifier would be necessary. However, since the services in this surgery are being performed by different individuals, modifiers will be necessary to ensure payment for both surgeons.

In this case, it is imperative that coordination with the surgeon's office is done to ensure reimbursement of the work in the postoperative period of the surgery. All involved must agree on the code being billed and the appropriate modifiers appended to the CPT codes that represent the services performed by the billing providers.


-54 for surgical care only
-55 or postoperative management only
-56 preoperative management only

There must be an agreement for transfer of care between the providers prior to the surgery. If the transfer of care does not occur, the services should be reported by the appropriate E/M service.


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