COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed. In addition to the individual requirements associated with the billing of a selected E/M  code, in order to receive payment from Medicare for a service, the service must also be
considered reasonable and necessary. Therefore, the service must be:

? Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (that is, not provided mainly for the convenience of the beneficiary, provider, or supplier); and

? Compliant with the standards of good medical practice. The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD)  diagnosis and procedure codes.


CURRENT PROCEDURAL TERMINOLOGY CODES

Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.