Description
Office or other outpatient visits for evaluation and management services may not be billed for patients while admitted to a hospital setting.
Affected Code(s)
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 3, §40.2- Determining Covered/Noncovered Days and Charges, §40.2.2- Charges to Beneficiaries for Part A Services, §140.3.1- Shared Systems and CWF Edits
8. Medicare Claims Processing Manual, Chapter 4, §290.2.1- Revenue Code Reporting
9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6- - Evaluation and Management Service Codes - General (Codes 99202 - 99499), §30.6.9.1- Payment for Initial Hospital Inpatient or Observation Care Services and Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services), §30.6.9.2- Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management (Codes 99231-99239), §30.6.10- Consultation Services, and §190 - Medicare Payment for Telehealth Services
10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
11. CMS Transmittal 10505, Change Request 12071 12/4/2020 Summary of Policies in the Calendar Year 2021 Medicare Physician Fee Schedule Final Rule, Office/Outpatient Evaluation & Management Visits
12. AMA CPT Codebook