Awareness : Frequently Asked Questions

Evaluation and Management (E/M) FAQs-Scenarios


  • Question: If a patient is seen in the emergency department, then admitted to the hospital, how should this be billed?

    Answer: “As stated in the CMS Internet-only Manual:

    Contractors pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. ” Source

  • Question: We treated a patient in the office on an emergency basis. CPT® codes 99212-25 (Office or other outpatient visit, with modifier 25 to indicate a significant, separately identifiable E/M visit on the same date as another procedure), 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) and 51705 (Change of cystostomy tube; simple) were billed. Can we be reimbursed for the office ER code 99058?

    Answer: Current Procedural Terminology® (CPT®) code 99058 is not a recognized service billable to the Medicare program. The services are billed according to the actual level of care provided to the patient. There is no additional reimbursement for disruption of other scheduled office services. Source

  • Question: We submitted a claim with HCPCS code 99233 (Subsequent hospital care) to Medicare and it was downcoded to 99232. Upon inquiring why this change was made, we were told levels were compared to levels of other doctors who were seeing the patient on the same day. Is this correct?

    Answer: No, this is not correct.

    In order for the Medical Review department to downcode an E/M service, the documentation is reviewed. In this case, the nurse reviewer must have been unable to identify all elements required for the level of care being billed. In all cases, you should review the records you submit to verify if the correct level of care was selected based on the 1995 or 1997 E/M guidelines. If you disagree with the findings, you may request an appeal, wherein a new reviewer will look at the documentation provided. Source