LCD Reference Article Billing and Coding Article

Billing and Coding: E&M Coding for Oral Surgeons

A56006

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56006
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: E&M Coding for Oral Surgeons
Article Type
Billing and Coding
Original Effective Date
06/07/2018
Revision Effective Date
01/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Article Guidance

Article Text

Palmetto GBA has determined that Provider Specialty 19 (oral surgeons) is appropriate to file E&M claims (99202-99215), in a limited fashion, when evaluating patients for sleep apnea to determine their suitability for placement of an oral device. All requirements for the E&M code selected must be met to bill the appropriate level of care. After a decision to perform the surgery is made, any preoperative or postoperative visits will be considered to be part of the bundled payment for the surgery.

Response To Comments

Number Comment Response
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(9 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
99202 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED.
99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 30 MINUTES MUST BE MET OR EXCEEDED.
99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED.
99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 60 MINUTES MUST BE MET OR EXCEEDED.
99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL
99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 10 MINUTES MUST BE MET OR EXCEEDED.
99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 20 MINUTES MUST BE MET OR EXCEEDED.
99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 30 MINUTES MUST BE MET OR EXCEEDED.
99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 40 MINUTES MUST BE MET OR EXCEEDED.
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1 Codes

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2024 R7

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 99202, 99203, 99204, 99205, 99212, 99213, 99214 and 99215. This revision is due to the 2024 Annual/Q1 CPT/HCPCS Code Update and is effective for dates of service on or after 1/1/24.

02/16/2023 R6

Under CMS National Coverage Policy added the regulation “Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.” Under Article Text revised first sentence to read, “Palmetto GBA has determined that Provider Specialty 19 (oral surgeons) is appropriate to file E&M claims (99202-99215), in a limited fashion, when evaluating patients for sleep apnea to determine their suitability for placement of an oral device.” Typographical errors were corrected throughout the article.

09/29/2022 R5

Under CPT/HCPCS Codes Group 1: Codes the code range was separated out into individual codes.

01/01/2022 R4

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 99211. This revision is due to the 2022 Annual CPT®/HCPCS Code Update and becomes effective on 1/1/2022.

01/01/2021 R3

Under CPT/HCPCS Codes Group 1: Codes deleted 99201 and changed descriptors for 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214 and 99215. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

10/17/2019 R2

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles.

02/21/2019 R1

Under CPT/HCPCS Codes Group 1: Codes added 99201-99215.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L36593 - Polysomnography
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
12/21/2023 01/01/2024 - N/A Currently in Effect You are here
02/07/2023 02/16/2023 - 12/31/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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