TMPPM 2010 > Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook > Physician > Procedures and Services > Physician Evaluation and Management (E/M) Services > Office or Other Outpatient Hospital Services

6.3.50.1 Office or Other Outpatient Hospital Services

6.3.50.1.1 New and Established Patient Services

A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient or other ambulatory facility. New patient visits are limited to one every three years, per client, per provider.

An established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility:

When an office visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, the office visit must be billed as an established patient visit. If a new patient visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, then the new patient visit will be denied.

Modifier 25 must be used to describe circumstances in which an office visit was provided at the same time as other separately identifiable services (e.g., THSteps visits and minor procedures). This modifier must be appended to the evaluation code when the services rendered are distinct, provided for a different diagnosis, or performed for different reasons. Both services must be documented as distinct and documentation must be maintained in the medical record and made available to Texas Medicaid upon request.

An established patient visit that is billed with the same date of service as a new patient visit by the same provider will be denied as part of another procedure except when the established patient visit is billed with a new THSteps medical checkup.

Office visits (procedure codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215) provided on the same date of service as a planned procedure (minor or extensive) are included in the cost of the procedure and are not separately reimbursed. An office visit procedure code for a separately-identifiable service performed on the same day as a planned procedure may only be reimbursed after submitting an appeal with medical documentation that indicates the visit was for a separately-identifiable service. Modifier 25 must be appended to the E/M code.

Office visit procedure code 99211, 99212, 99213, 99214, or 99215 must be billed by the same provider with the same date of service as a group clinical visit. The following office visit procedure codes performed for a separately-identifiable service on the same day as a group visit may only be reimbursed after submitting an appeal with medical documentation indicating that a separately-identifiable service was performed. Modifier 25 must be appended to the E/M code:

Refer to: Subsection 6.3.50.4, "Group Clinical Visits" in this handbook for additional information.

Procedures that are included in the E/M service (e.g., binocular microscopy, noninvasive ear or pulse oximetry for oxygen saturation, etc.) are denied as part of another procedure when billed by the same provider with the same date of service as one of the following office or outpatient consultation visit procedure codes:

Emergency department-based physicians or emergency department-based groups may not bill charges for inconvenience or after hours services (procedure code 99050, 99056, or 99060).