pqri measure coding and reporting principles - Indiana Academy of ...

service or other face-to-face service with the patient is performed, then this patient remains a new patient
for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of
an E/M service or other face-to-face service with the patient does not affect the designation of a new
patient.
Newby Note: If more than one evaluation and management (face-to-face) service is
provided on the same day to the same patient by the same physician or more than one
physician in the same specialty in the same group, only one evaluation and management
service may be reported unless the evaluation and management services are for unrelated
problems. Instead of billing separately, the physician should select a level of service
representative of the combined visits and submit the appropriate code for that level.
Physicians in the same group practice but who are in different specialties may bill and be
paid without regard to their membership in the same group.
There is no difference if the group physicians are located in the same or different
buildings. Therefore, even though a physician may be located on another campus, if a
patient previously cared for by the same specialty physician in the same group within the
previous three years is seen by a group physician of the same specialty at a setting apart
from where his/her care is generally rendered and where his/her medical records may be
located, for billing purposes, that patient remains an established patient for that same
group, same specialty physician. It is the group’s responsibility to coordinate record
keeping when different locations are involved.
Changing Group Practices
Dr. Smith leaves his/her practice in Indianapolis to join a new practice in Carmel. If Dr.
Smith, or another physician of the same specialty in the Carmel practice, has not provided
any professional services to that patient within the past three years, then Dr. Smith would
consider the patient a new patient. If Dr. Smith has rendered professional services to the
patient in either the Indianapolis or Carmel practice within the past three years, the
patient is considered established to Dr. Smith. If Dr. Smith saw the patient in Indianapolis,
but one of the Carmel physicians sees the patient, the patient would be considered new.
B. Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems
As for all other E/M services except where specifically noted, Carriers may not pay two E/M office visits
billed by a physician (or physician of the same specialty from the same group practice) for the same
beneficiary on the same day unless the physician documents that the visits were for unrelated problems in
the office or outpatient setting which could not be provided during the same encounter (e.g., office visit
for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain
following an accident).
C. Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility
Carriers may not pay a physician for an emergency department visit or an office visit and a
comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided
in sites other than the nursing facility into the initial nursing facility care code when performed on the
same date as the nursing facility admission by the same physician.
D. Drug Administration Services and E/M Visits Billed on Same Day of Service
Carriers must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug
administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January
1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule,
November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005).
Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets
a higher complexity level than CPT code 99211) is performed, in addition to one of these drug
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*All CPT Codes, Descriptions, and Two-Digit Modifiers
Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01
Copyright 2007 Newby Consulting, Inc.