Coding: Evaluation & Management FAQ
What code do I use for Medicare patients the first time I see them in the hospital?
Use the Initial Hospital Visit codes (99221-99223). If you are the admitting physician, add the AI modifier to the code.
Now that we can't use the Consultation codes for Medicare patients, what code do we use for the first visit to our office?
If no other provider of the same specialty in your practice has provided any face-to-face service to the patient in the last three years, you bill a New Patient visit (99201-99205). If the patient has been seen within the last three years, you bill an Established Patient visit (99211-99215). NOTE: Hepatology is not a separate specialty from Gastroenterology. Review information on Medicare specialty codes.
What code do we bill when we are asked to see a Medicare patient in the emergency room?
Use the Emergency Department Visit codes (99281-99285).
Can we still use the Consultation codes for private payors?
Each individual payor will have their own policy on the use of the Consultation codes. If you have not been notified, it is advised that you check with the payor prior to billing the Consultation codes.
What if a Medicare patient was seen within the last three years but is referred to our office for another problem?
Since the patient was seen within the last three years, you must bill for an Established Patient visit (99211-99215). This depends strictly on the timeframe of the last visit, not the patient presentation.
How do I bill for a patient seen in our office prior to a screening colonoscopy with no GI symptoms and who is otherwise healthy?
A visit prior to a screening colonoscopy for a healthy patient is not billable.
If a patient is referred to our office for a screening colonoscopy and the patient is on Coumadin, can we bill for the visit?
Yes. If the patient requires some intervention on the part of the gastroenterologist prior to the procedure, you can bill a New Patient or Established Patient visit, depending on whether the patient has received any face-to-face service by any provider of the same specialty in your office within the last three years.
If a nurse practitioner or physician assistant sees a new patient in the office and then discusses the patient with a physician, can we bill the visit under the physician?
No. New Patient visits must be billed under the nurse practitioner/physician assistant’s NPI/provider number unless the payor tells you otherwise in writing.
If a patient presents to our office with symptoms, such as difficulty swallowing, and after taking a history and examining the patient the physician decides that the patient needs an immediate procedure, can we get paid for both the procedure and the visit on the same day?
Yes. As long as you have a documented E/M service during which the decision was made to do the procedure, you can bill both the procedure and the visit with a 25 modifier on the visit. You will receive full payment for both services.
