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Printed Date: 9/22/2015
This E/M article shares helpful hints when submitting services to Medicare Part B for processing. For regulations regarding physician/non-physician practitioner billing, please refer to the Centers for Medicare and Medicaid Services (CMS) Internet Online Manual, Publication 100.04, Chapter 12 (PDF, 1.13 MB).
Medical Necessity Determines Payment
Medical necessity of a service is the overarching criterion for payment. Do not submit a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which the service is submitted. Select the code for the service based upon the content of the service. The service furnished and submitted must meet the definition of the code.
Physicians in the same group practice, but who are in different specialties, may bill and be paid without regard to their membership in the same group. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems, which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident). Otherwise, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
Two office visits submitted for the same beneficiary, same physician/same specialty in same group on the same day are not payable. Palmetto GBA will deny the second visit submitted. This applies to CPT codes 99201-99215. A review would be necessary for Palmetto GBA to consider a second office visit on the same date of service. On review, the provider must clearly indicate the visits were for unrelated problems in the office/outpatient setting, which could not have been provided during the same encounter.
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Last Updated: 02/13/2018