In this Fee Schedule CPT® codes that contain
explanatory language specific to Arizona are preceded by Δ. Codes, however, that are unique
to Arizona and not otherwise found in CPT®-4 are preceded by an AZ identifier and numbered
in the following format: AZ0xx-xxx.
The evaluation and management guidelines adopted by reference may be found in the Current
Procedural Terminology®, Fourth Edition (“CPT® book”) published by the AMA and is
reprinted, in part, below with permission. To the extent that a conflict may exist between an
adopted portion of the CPT®-4 and a code, guideline, identifier or modifier unique to Arizona,
then the Arizona code, guideline, identifier or modifier shall control.
A. CLASSIFICATION OF EVALUATION AND MANAGEMENT (E/M) SERVICES: The
E/M section is divided into broad categories such as office visits, hospital visits, and
consultations. Most of the categories are further divided into two or more subcategories of
E/M services. For example, there are two subcategories of office visits (new patient and
established patient) and there are two subcategories of hospital visits (initial and
subsequent). The subcategories of E/M services are further classified into levels of E/M
services that are identified by specific codes. This classification is important because the
nature of work varies by type of service, place of service, and the patient’s status.
The basic format of the levels of E/M services is the same for most categories. First, a
unique code number is listed. Second, the place and/or type of service is specified, eg,
office consultation. Third, the content of the service is defined, eg comprehensive history
and comprehensive examination. (See “Levels of E/M Services” for details on the content
of E/M services). Fourth, the nature of the presenting problem(s) usually associated with
a given level is described. Fifth, the time typically required to provide the service is
specified. (A detailed discussion of time is provided below).
B. DEFINITIONS OF COMMONLY USED TERMS: Certain key words and phrases are
used throughout the E/M section. The following definitions are intended to reduce the
potential for differing interpretations and to increase the consistency of reporting by
physicians in differing specialties. E/M services may also be reported by other qualified
health care professionals who are authorized to perform such services within the scope of
their practice.
New and Established Patient: Solely for the purposes of distinguishing between new
and established patients, professional services are those face-to-face services rendered
by physicians and other qualified health care professionals who my report evaluation
and management services reported by a specific CPT code(s). A new patient is one
who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same
specialty and subspecialty who belongs to the same group practice, within the past three
years.
An established patient is one who has received professional services from the
physician/qualified health care professional or another physician/qualified health care
professional of the exact same specialty and subspecialty who belongs to the same
group practice, within the past three years
In the instance where a physician/qualified health care professional is on call for or
covering for another physician/qualified health care professional, the patient’s
encounter will be classified as it would have been by the physician/qualified health care
professional who is not available. When advanced practice nurses and physician
assistants are working with physicians they are considered as working in the exact same
specialty and exact same subspecialties as the physician.
No distinction is made between new and established patients in the emergency
department. E/M services in the emergency department category may be reported for
any new or established patient who presents for treatment in the emergency department.
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