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 can 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 physician 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.

The practice should deem which plan they will follow for NPP.

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. Consultation codes are no longer accepted by Medicare. 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. Can this visit be billed?

A. Evaluation of a patient only 10 days postoperative with hematuria would not be considered a billable visit. Hematuria can be a normal complication 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:

  • local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
  • subsequent to the decision for surgery; one related E&M encounter on the date immediately prior to or on the date of the procedure (including history and physical)
  • immediate postoperative care, including dictating operative notes, talking with the family and other providers
  • writing orders
  • evaluating the patient in the post-anesthesia recovery area
  • typical postoperative follow-up care

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.

Q.  The urologist was called into the emergency room to evaluate a patient with gross hematuria. Can a urologist report an emergency room visit?

A.  There may be some instances where a urologist tells a patient to meet him at the Emergency Department (ED) of the local hospital. A urologist may charge the appropriate Emergency Department Service evaluation & management codes if the patient is seen in the ED. These codes include 99281-99285 based on the level of the key components obtained during the visit.

Q.  What is the difference between transfer of care to a specialist versus a request for consultation – Medicare and private?

A.  The difference between a transfer of care and a request for consultation is the request itself. When a physician turns over the care of a patient for a specific treatment, this is considered transfer a care. There is no request for a physician to do an evaluation and then treat the patient. There are four components of a consultation: Request, Reason, Render and Report. All four of these must be met. The most important are the request and the report that goes back to the requesting physician. Medicare does not accept consultation codes any more. Some private insurers do. Check before submitting your evaluation and management services claims to see who will accept consultation codes.

When auditing medical charts should the 1995 or 1997 Evaluation & Management Documentation Guidelines should we use? There is no prerequisite on which guidelines to use when auditing charts. The only difference between the 1995 and 1997 guidelines is the physical examination. The 1995 guidelines use comments on body areas and organ systems. The 1997 guidelines use bullets during the examination to determine the level. Most auditors, in the absence of specific guidance from contractors, will use what ever documentation guidelines will benefit the physician.

Q. Our urologist dictates the office notes and gives them to our transcriptionist. At the end of the notes, the transcriptionist types "Dictated but not read." The doctor does not review or sign the dictation. Will this pass an audit?

A. No. As any audit is based on documented notes in a patient's chart, the physician is responsible for the accuracy of his dictated material. The urologist must read and sign all documents in the patient's chart not only for medical and auditing reasons, but also for legal reasons.

Q. Our patient saw his urologist and internist on the same day - two entirely different physicians in two different practices. The claim for the urologist was denied. Can we appeal this decision?

A. Yes, this is definitely a case where an appeal should be pursued. Submit a cover letter with your appeal and outline the reason for the visit, medical necessity, and ask that this claim be reconsidered.

Q. Can I bill Medicare for 99211 "nurse" visit with the chemotherapy administration code?

A. No. The lowest level E/M service 99211 will not be reimbursed with the chemotherapy administration code.

Q. Will a -25 modifier still be required when an E&M Service (99212-99215 or 99202-99205) is provided on the same day with chemotherapy administration?

A. As of January 1, 2004, if an evaluation and management (E&M) service is provided by the physician or other Medicare approved healthcare provider (PA/NP) on the same day as the chemotherapy injection, then the E&M service must have the -25, Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service modifier appended to it. Make sure your documentation describes the medical necessity of the E&M service provided.

Q.  What is the difference between observation care and an inpatient admission to the hospital?

A.  A patient can be given either an observation status or inpatient status in a hospital depending upon the patient, their presenting problem and how long the physician thinks they will need to stay in the hospital. The decision for inpatient hospital admission is complex and based on physician judgment and the need for medically necessary hospital care. The patient will not know their status unless they either ask or are told because the rooms look the same. A patient is usually assigned inpatient status if there is a stay required longer than two midnights or if the patient has a severe problem that requires highly technical, skilled care. The physician must order the admission and the hospital must formally admit the patient in order for the patient to be placed in inpatient status. This translates into the intensity of the services required: blood tests, x-rays, physician examination or surgery. The same patient might be assigned observation status if they're not sick enough to require inpatient status but are too sick to be cared for in the physician office. Observation services are hospital services given to help the physician decide if the patient needs to be admitted as an inpatient or can be discharged. Observation services may be given in the emergency department or another area of the hospital.

There are guidelines published in the Medicare Benefit Policy Manual to determine who is assigned to inpatient versus observation status.

Some patients will be placed in observation status if they have received outpatient surgery and need to stay in the hospital for a short recovery period. The physician will generally know if a procedure will require an inpatient stay in the hospital versus being in observation status and should make the request prior to the surgery.

It is important to research your local hospital's policy on inpatient versus outpatient status and educate your physician. If improperly applied, a patient could be responsible for an extensive bill from the hospital if the incorrect status is applied.