Tag: #E/Mcodes

Posted in #unitedhealthcare, Updates

UHC Commercial Plan New Reimbursement Policy Alert: Physician Billing (facility) 08/01/21

Posted on by KR2Medical Billing

According to UHC Commercial Plans May Reimbursement Policy Update:

Starting 08/01/2021 the new reimbursement policy will apply to E/M (99202-99215) codes. This policy applies to services billed on professional (HCFA-1500) form and UB 04 (facility) form.

This policy applies to services that are performed in POS 19 (Off Campus Outpatient Hospital) or POS 22 (On Campus Outpatient Hospital) without any additional medical surgical service on the same day of service by the same provider.

The E/M codes will be only reimbursed when billed with a POS (place of service) 11.

For Provider Based Facility Clinic visit with revenue code 051X:

Facility Claim (UB04) – provider based facility clinical visit services with a Revenue code 051X will not be separately reimbursed IF a coinciding Professional Claim (HCFA-1500) is billed and reported with POS 11 and/or billed with the same E/M codes (99202-99215).

When will this policy NOT apply?

When a provider performs E/M codes AND a medical surgical service ON THE SAME DOS, the professional and facility claim (if applicable) WILL NOT BE SUBJECT TO THE ABOVE POLICY.

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Posted in Insurance, Training, Updates

EmblemHealth (NY) E&M codes reimbursement policy: updated for 2021

Posted on by KR2Medical Billing

With the changes to the E&M codes, for the year 2021, EmblemHealth updated their reimbursement policy for providers.

The following is now the guidelines/reminder for E&M Reimbursement: documentation requirements

• The CPT® coding guideline updates only apply to 99202-99215.
– Other codes within the evaluation and management section of the CPT book are still subject to previous reimbursement policies.
• Chief complaint (Reason for visit) must be clearly documented.
• A clinically appropriate history and exam are still required.
• Medical Necessity, Medical Decision Making and Assessment & Plan are required to be
documented.
• When time is the determining factor for code selection, all start and stop times must be documented to substantiate total time on the date of the encounter.