When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.
During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.
Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.
Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.
SAME-DAY OUTPATIENT VISITS
Same-Day Outpatient Visits (Under age 21 only)
• Same-day outpatient visit policy does not apply to state-funded foster children (aid category 15).
• Same-day outpatient visits are not covered if the patient’s diagnosis is simple, or if the condition requires non-complex care.
• Same-day outpatient visits may be considered for payment for recipients under 21 if the visit can be justified when:
* * the physician needs to check on the progress of an unstable patient treated earlier in the day;
* * an emergency situation necessitates a second visit on the same day as the first; or
* * any other occasion arises in which a second visit within a 24-hour period is necessary to ensure the provision of medically necessary care to the recipient.
• Two same-day outpatient visits per specialty per recipient are allowed. In billing for the second same-day outpatient visit, no higher level visit than 99212 should be billed. Procedure codes 99211 and 99212 may be billed twice on the same day, or in combination.
• The patient’s medical record must be available for review and must substantiate the need for the second same-day visit.
• An outpatient visit and critical care services may be billed on the same day for the recipient.
• An emergency department visit and critical care services may be billed on the same day for the recipient.
• If a KIDMED screening has been paid, no higher level office visit than 99212 is payable for the same recipient, same date of service and same attending provider.
• A same day follow up office visit for the purpose of fitting eyeglasses is allowed, but no higher level office visit than 99211 should be billed for the fitting.
Same Day Outpatient Visits (Age 21 and over)
If a preventive medicine evaluation and management service has been paid, no office visit of a higher level than Procedure code 99212 is reimbursable for the same recipient, same date of service, and same attending provider. Refer to page 77 for specifics regarding preventive medicine evaluation and management services for adults.
