The Lowdown on Billing Evaluation and Management Codes Can SLPs and audiologists use E/M codes? The answer is no—and yes. Bottom Line
Free
Bottom Line  |   August 01, 2014
The Lowdown on Billing Evaluation and Management Codes
Author Notes
  • Neela Swanson is ASHA director of health care coding policy. nswanson@asha.org
    Neela Swanson is ASHA director of health care coding policy. nswanson@asha.org×
  • Janet McCarty, MEd, CCC-SLP, is ASHA private health plans advisor. jmccarty@asha.org
    Janet McCarty, MEd, CCC-SLP, is ASHA private health plans advisor. jmccarty@asha.org×
Article Information
Practice Management / Bottom Line
Bottom Line   |   August 01, 2014
The Lowdown on Billing Evaluation and Management Codes
The ASHA Leader, August 2014, Vol. 19, 28-29. doi:10.1044/leader.BML.19082014.28
The ASHA Leader, August 2014, Vol. 19, 28-29. doi:10.1044/leader.BML.19082014.28
If you are a speech-language pathologist or audiologist and spend time taking a patient’s history and counseling the patient and family members on options, can you bill for that time using evaluation and management codes? The answer is not clear-cut. It mostly depends on the patient’s health insurance coverage.
What are E/M codes?
Evaluation and management codes—99201 through 99499 in the CPT system (Current Procedural Terminology © American Medical Association)—describe patient encounters, typically with physicians. Each E/M code represents a different type of encounter, such as office visit, hospital visit or consultation, and the level of care provided. For example, CPT 99214 (office or other outpatient visit for the evaluation and management of an established patient) denotes an office visit with an established patient with severe presenting problems (see sidebar below).
Who can use E/M codes?
The E/M descriptors indicate that the codes may be billed by physicians or other qualified health care providers. However, various payers have different definitions of “qualified” provider. E/M codes are designed to capture traditional physician office visits that include physical exams and medical decision-making. Medicare, therefore, does not allow audiologists, SLPs, and most other nonphysician specialists—except nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants—to use E/M codes.
Many other payers follow Medicare policy. For example, TRICARE, the health care program of the U.S. Department of Defense, notes that neither audiologists nor SLPs are authorized to bill E/M codes. Similarly, UnitedHealthcare revised its speech-language treatment policy in 2013 to deny reimbursement for E/M codes billed by SLPs. And in 2012, Aetna indicated that audiologists, SLPs and other nonphysician specialties could not use E/M codes.
Some colleagues in private practice report that they are successfully reporting E/M codes. How?
Although many payers follow Medicare guidelines, some may allow nonphysician providers to use E/M codes. The key is to check with each payer and get the response in writing before billing E/M codes. Additionally, the clinician and health plan must understand if and how the E/M codes will be billed in combination with other codes, such as 92523 (evaluation of speech sound production and language) or 92557 (comprehensive audiometry threshold evaluation).
Some clinicians have found that specific health plans do recognize E/M codes and bill them successfully alongside the codes for audiology and speech-language procedures. For example, a member reports that Blue Cross Blue Shield of New Jersey, after extensive negotiation, did agree to allow audiologists to bill a limited number of E/M codes, though payment has been inconsistent.
Clinicians should never bill E/M codes without first obtaining clear, written acceptance from the patient’s payer. Even clinicians who have successfully billed for E/M services without prior verification should get written authorization, because future audits could prompt payers to ask clinicians to return the payment due to inappropriate billing.
Despite these sporadic instances of successful E/M code use, clinicians should recognize and be familiar with their many limits. Medicare guidelines for using of E/M codes are available at bit.ly/em-guide.
Are there any E/M codes specifically for use by nonphysician providers?
Yes, a series of CPT codes for evaluation and management describe medical team conferences (99366–99368) for both direct and nondirect patient care and specifically allow “participation by nonphysician qualified health care professionals.” Medicare, however, does not cover these team conference codes, considering these services as already captured in standard E/M codes. Private payers, however, may cover them.

What Does an E/M Code Look Like?

E/M codes specify the location of the visit, the patient’s new or established status, and the severity of the patient’s complaint. Here’s an example.

99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A detailed history.

  • A detailed examination.

  • Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

0 Comments
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
August 2014
Volume 19, Issue 8