Payment for Office or Other Outpatient Evaluation and Management (E/M ) Visits (Codes 99201 - 99215)
This transmittal clarifies and corrects the definition of "new patient" and "physician" for billing evaluation and management (E/M) services
currently stated in Medicare Claims Processing, Pub. 100-04, Chapter 12, §30.6.7, and updates the policy on billing E/M services with drug administration codes. In Change Request (CR) 3631, carriers were instructed not to allow payment for CPT code 99211 with or without modifier -25 if it is billed with a nonchemotherapy or chemotherapy drug infusion code or with diagnostic or therapeutic injection codes. This transmittal will update the E/M manual section indicating Medicare will pay for a medically necessary office/outpatient visit (when it meets a higher complexity level than CPT code 99211) billed on the same day as a drug administration service as specified. Modifier -25 must be appended to the E/M service to identify that a significant and separately identifiable E/M service (higher complexity than CPT code 99211) was performed. There are different effective dates for the chemotherapy and nonchemotherapy drug infusions codes from the therapeutic and diagnostic injection codes.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: October 28, 2005
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.