Medicare Advantage

Medical Policy

Notification

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

Notification Issued Date:

Title:

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

Policy #:

MA00.037l

Policy

PROFESSIONAL PROVIDERS

When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the professional provider must submit a CMS-1500 claim form or the electronic equivalent 837p for the office-based service. In such cases, the office-based service fee is inclusive of the professional provider service performed, as well as the office-based overhead (i.e., practice expense).

FACILITIES

When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the facility is not eligible to receive reimbursement for the professional provider office-based services (i.e., room charge) and any item or service included in the payment to the professional provider. If a UB04 claim form or the electronic equivalent 837i is received from the facility for the office-based services, reimbursement will not be made to the facility.

The facility is eligible to receive reimbursement for any covered ancillary service (e.g., laboratory test, radiologic study) related to the office visit or consultation according to their contract.

Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) products require that the member obtain capitated services at the primary care provider's (PCP's) designated capitated site. Capitated services obtained from providers other than the member's PCP must be pre-approved by the Company.

BILLING SCENARIO

A professional provider (e.g., physician specialist) completes an initial outpatient evaluation and management (E & M) service in their office or clinic that is located within a facility or on a facility campus.

Reimbursement to the professional provider for an E & M service includes payment for the E & M services and any costs associated with office-based overhead to the professional provider.
The facility is not eligible to receive reimbursement for a facility component for the outpatient E & M service performed by the consulting professional provider because payment to the professional provider is inclusive of the office-based overhead (i.e., practice expense).

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

For Preferred Provider Organization (PPO) members to receive the highest level of benefits, diagnostic services should always be performed by a participating professional provider. Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) require that the member obtain capitated services at the primary care physician's (PCP's) designated capitated site.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, professional provider services performed in certain outpatient settings are covered under the medical benefits of the Company's Medicare Advantage products.

Description

Professional providers may perform outpatient office-based services (e.g., office visit, outpatient consultation, professional interpretation and report) in a variety of settings. These settings include, but are not limited to:

A freestanding office
An office or outpatient clinic located within a hospital, on or within a hospital facility campus, hospital affiliate, hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room)

As used in this policy:

Professional provider refers to the professional provider who performs the health care service, as well as to any professional provider in the same provider group practice.
Facility refers to a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate--owned site, division, or other location (e.g., clinic, treatment room).
Office-based service refers to office visits, outpatient consultations, minor office procedures, and any related items or services included in the payment of these services.
Capitation is the reimbursement that a participating facility, ancillary provider (e.g., freestanding outpatient radiology site), or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for a Health Maintenance Organization Point-of-Service (HMO-POS) member who utilizes their referred benefit.

References

Company Hospital Manuals.

Company Provider Manuals.

Coding

CPT Procedure Code Number(s)

See Attachment A.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

See Attachment A.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.037l:

01/01/2024	This AmeriHealth New Jersey Medicare Advantage policy will become effective 01/01/2024.
01/01/2023	This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2023. The following CPT/HCPCS Code has been added to this policy: G0323 The following CPT codes have been removed from the policy.: 99318, 99354, and 99355 The following CPT/HCPCS Code have had narrative revisions: 92284, 99417, 99483, G0442, G0444, and G2212

Revisions From MA00.037k:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022

The following CPT Codes have been removed from this policy:
0462T and 0463T

The following HCPCS code have been removed from the policy.:
G2064 and G2065

CPT code 99211 has had a narrative revision:
From: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.

To: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional

Revisions From MA00.037j:

01/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021

The following CPT Codes have been added to the policy:
99417 and 99439

The following HCPCS codes have been added to the policy:
G2211, G2212, G2214

HCPCS code G2058 has been removed from the policy.

Revisions From MA00.037i:

10/01/2020

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2020.

The narrative for the following HCPCS code has been revised: G2011.

Revisions From MA00.037h:

01/13/2020

This policy update becomes effective 01/13/2020. The policy update reaffirms the Company's continuing position on Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus. However, the following five consultation codes will be removed from Attachment A because they are not eligible for reimbursement at all: 99241, 99242, 99243, 99244, 99245.

Revisions From MA00.037g:

01/01/2020

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2020.

The following CPT codes have been added to the policy: 99421, 99422, 99423, 99473, 99474.

The following HCPCS codes have been added to the policy: G2058, G2061, G0262, G2063, G2064, G2065.

The following CPT code has been deleted from the policy: 99444.

The narrative for the following CPT code has been revised: 93790.

Revisions From MA00.037f:

01/01/2019

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT codes have been added to the policy:

92273: Electroretinography (ERG), with interpretation and report; full field (ie, ffERG, flash ERG, Ganzfeld ERG)

92274: Electroretinography (ERG), with interpretation and report; multifocal (mfERG)

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT code has been termed from the policy:

92275: Electroretinography with interpretation and report

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT narratives have been revised in this policy:

93924

FROM: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional

TO: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system, or leadless pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional

93927

FROM: Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional

TO: Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional

93928

FROM: Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional

TO: Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional

This policy has been identified and updated for the HCPCS code update effective 01/01/2019.

The following HCPCS code has been added to the policy:
G2011: Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention, 5-14 minutes

Revisions From MA00.037e:

01/01/2018

This policy has been identified for the CPT/HCPCS code update.

The following CPT/HCPCS codes have been added to this policy, effective 01/01/2018:

93792, 93793, G0511, G0512, G0513, G0514, 95249, 99483, 99484, 99492, 99493, 99494

The following CPT codes have been deleted from this policy, effective 01/01/2018:

0180T, 99393, 99364

The following CPT code has been revised to this policy, effective 01/01/2018:

95251

Revisions From MA00.037d:

12/27/2017

This policy will become effective 12/27/2017. When a professional provider

The policy was updated to be consistent with current template wording and format.

The following HCPCS code been added to this policy:

G0463: Hospital outpatient clinic visit for assessment and management of a patient

Revisions From MA00.037c:

01/01/2017

This policy has been identified for the CPT code update.

The following CPT codes have been added to this policy, effective 01/01/2017: 96160, 96161, 0462T, 0463T, 0464T, D9311, G0501, G0505, G0506, G0508, G0509

The following CPT code has been deleted from this policy, effective 12/31/2016: 99420

Revisions From MA00.037b:

01/01/2016

This policy has been identified for the CPT/HCPCS code update, effective 01/01/2016.

The following CPT/HCPCS been added to this policy:

0405T, G0296, 99177, 99415, 99416

The following CPT/HCPCS narratives have been revised in this policy:

99174, 99354, 99355

Revisions From MA00.037a:

01/02/2015

This is a coding update.

Revisions From MA00.037:

01/01/2015

This is a new policy.

Version Effective Date:

1/1/2024

Version Issued Date:

1/1/2024

Version Reissued Date: