Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.10.39k


Attachment:A

Policy #:00.10.39k

Description:CPT/HCPCS Codes

Title:Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



This attachment lists Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes that represent office visits and outpatient consultations that are considered to be office-based services. This list may not be all-inclusive and does not contain minor office procedures or any related items or services that are included in the payment of an office visit or outpatient consultation.

Table I: CPT CODES

CPT Codes Representing Office Visits and Outpatient Consultations
Code
0405T
0462T
0463T
0464T
34839
92002
92004
92012
92014
92015
92071
92072
92081
92082
92083
92265
92270
92273
92274
92283
92284
92310
92311
92312
92313
92314
92315
92316
92317
92340
92341
92342
92352
92353
92354
92355
92358
92370
92371
93010
93016
93018
93042
93227
93228
93272
93293
93294
93295
93297
93298
93790
93792
93793
94016
94777
95249
95251
96004
96127
96160
96161
98960
98961
98962
99172
99173
99174
99177
99188
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99241
99242
99243
99244
99245
99318
99354
99355
99358
99359
99366
99367
99368
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99401
99402
99403
99404
99406
99407
99408
99409
99411
99412
99415
99416
99421
99422
99423
99429
99441
99442
99443
99450
99455
99456
99461
99473
99474
99483
99484
99490
99492
99493
99494
99497
99498

TABLE II: HCPCS CODES

HCPCS Codes Representing Office Visits and Outpatient Consultations
Code
Code Narrative
D0120
Periodic oral evaluation - established patient
D0140
Limited oral evaluation - problem focused
D0150
Comprehensive oral evaluation - new or established patient
D0160
Detailed and extensive oral evaluation - problem focused, by report
D0170
Re-evaluation, limited, problem-focused (established patient, not postoperative visit)
D0180
Comprehensive periodontal evaluation - new or established patient
D9311
Consultation with a medical health care professional
G0175
Scheduled interdisciplinary team conference (minimum of three exclusive of patient care nursing staff) with patient present
G0250
Physician review, interpretation, and patient management of home inr testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests
G0296
Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)
G0379
Direct referral for hospital observation care
G0402
Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0405
Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
G0436
Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
G0437
Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes
G0438
Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
G0439
Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit
G0442
Annual alcohol misuse screening, 15 minutes
G0443
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
G0444
Annual depression screening, 15 minutes
G0445
High intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance
G0446
Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face-to-face, bi-annual, 15 minutes
G0447
Face-to-face behavioral counseling for obesity, 15 minutes
G0463
Hospital outpatient clinic visit for assessment and management of a patient
G0473
Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes
G0501
Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lift, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient, evaluation and management visit (list separately in addition to primary service)
G0505
Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home
G0506
Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)
G0508
Telehealth consultation, critical care, initial , physicians typically spend 60 minutes communicating with the patient and providers via telehealth
G0509
Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth
G0511
Rural health clinic or federally qualified health center (rhc or fqhc) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm), per calendar month
G0512
Rural health clinic or federally qualified health center (rhc/fqhc) only, psychiatric collaborative care model (psychiatric cocm), 60 minutes or more of clinical staff time for psychiatric cocm services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month
G0513
Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)
G0514
Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code g0513 for additional 30 minutes of preventive service)
G2011
Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention, 5-14 minutes
G2058
Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). (do not report g2058 for care management services of less than 20 minutes additional to the first 20 minutes of chronic care management services during a calendar month). (use g2058 in conjunction with 99490). (do not report 99490, g2058 in the same calendar month as 99487, 99489, 99491))
G2061
Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes
G2062
Qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes
G2063
Qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes
G2064
Comprehensive care management services for a single high-risk disease, e.g., principal care management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities
G2065
Comprehensive care management for a single high-risk disease services, e.g. principal care management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities
H0004
Behavioral health counseling and therapy, per 15 minutes
S0220
Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient is present); approximately 30 minutes
S0221
Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient is present); approximately 60 minutes
S0260
History and physical (outpatient or office) related to surgical procedure (List separately in
addition to code for appropriate evaluation and management service)
S0302
Completed early periodic screening diagnosis and treatment (EPSDT) service (List in
addition to code for appropriate evaluation and management service)
S0610
Annual gynecological examination, new patient
S0612
Annual gynecological examination, established patient
S0613
Annual gynecological examination; clinical breast examination without pelvic evaluation
S0620
Routine ophthalmological examination including refraction; new patient
S0621
Routine ophthalmological examination including refraction; established patient
S0622
Physical exam for college, new or established patient (List separately in addition to appropriate evaluation and management code)
S9117
Back school, per visit
S9150
Evaluation by ocularist
T1001
Nursing assessment/evaluation.

Version Effective Date: 01/01/2020
Version Issued Date: 01/06/2020
Version Reissued Date: N/A

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