CPT 99021 - 99499 - Evaluation management CPT codes

Evaluation and Management  CPT codes

Section     Code Range     Subsection     CodeCount    

First     Last         Section Total      


99201     99215     Office or Other Outpatient Services     10    
     99217     99220     Hospital Observation Services     4    
     99221     99239     Hospital Inpatient Services     11   
     99241     99275     Consultations     18   
     99281     99288     Emergency Department Services     6    
     99289     99290     Patient Transport     2    
     99291     99292     Critical Care Services     2    
     99295     99298     Neonatal Intensive Care     4    
99301     99316     Nursing Facility Services     8    
99321     99333     Domiciliary, Rest Home, Custodial Care Services     6    
99341     99350     Home Services     9   
99354     99360     Prolonged Services     7   
99361     99373     Case Management Services     5    
99374     99380     Care Plan Oversight Services     6    
99381     99429     Preventive Medicine Services     22   
99431     99440     Newborn Care     6   
99450     99456     Special Evaluation and Management Services     3    
99499     99499     Other Evaluation and Management Services     1


Billing Guide CPT code 99499

 Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.


 Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service.
 Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.

 In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

 Contractors shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the  provider's first E/M service to the inpatient during the hospital stay. Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M service that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service. Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual.




 In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s UPIN/PIN.

 In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician  practitioner rate. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose.


 • Physicians should us CPT code 99499 with modifier SC V07.31 (medically necessary service).

 • Procedure code 99499 SC V07.31 reimburses physicians, ARNPs, and Pas $27.00

 • The procedure may be submitted once per claim on the same date of service as other procedures.

 • Fluoride varnish may also be applied to a child’s teeth at the time of the Child Health Check-Up visit. It can also be billed with procedure code 99499 SC, as noted above.

 • If a child comes to the office for immunizations, the oralevaluation and fluoride varnish can be provided during the same visit and billed using 99499 SC 07.31 in addition to the immunizations service.

 • CHIP and Medikids are eligible for this service.


 This policy describes reimbursement for Evaluation and Management (E/M) services (99201–99499) reported by nonphysician health care professionals.



Reimbursement Guidelines

 CPT guidance instructs that E/M (CPT codes 99201-99499) should only be reported by Physicians or specific non-physician practitioners (NPP). In accordance with CMS guidelines, CMS will only pay for E/M services for nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM) provided they are allowed to bill for those services. Physician assistants (PA) are also allowed to provide the service as along asthe physician collaboration and general supervision rules are applied. UnitedHealthcare will not reimburse E/M services (CPT codes 99201-99499) when reported by nonphysician health care professionals not listed above.

 The National Correct Coding Initiative Policy Manual gives the following instruction: "Procedures should be reported with the most comprehensive CPT code that describes the services performed." The Current Procedural Terminology (CPT®) book has specific guidelines that give the following instruction: "Select thename of the procedure or service that accurately identifies the service performed." There are a wide variety of CPT and Healthcare Common Procedure Coding System (HCPCS) codes that specifically and accurately identify and describe the services and procedures performed by nonphysician health care professionals.

 For evaluation or re-evaluation services, physical and occupational therapists will not be reimbursed for E/M (CPT codes 99201-99499). Consistent with the coding guidelines from the Centers for Medicare and Medicaid Services (CMS), they will only be reimbursed for appropriate use of CPT codes 97001-97004.

 Providers are required to use the HCPCS informational modifiers GO (Services delivered under an outpatient occupational therapy plan of care) or GP (Services delivered under an outpatient physical therapy plan of care) when reporting codes 97001-97004 to distinguish procedures provided by different specialists within a multispecialty group.

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