TMPPM 2007 >36.3.4.1 Office or Other Outpatient Services

Outpatient services are defined as services rendered in an outpatient setting such as a physician office, ambulatory facility and/or other outpatient setting.

A new patient is defined as one who has not received any professional services from a physician or more than one physician of the same specialty within the same group practice within the past three years. Providers may use procedure codes 1-99201, 1-99202, 1-99203, 1-99204, and 1-99205 when submitting claims for new patient services provided in the office or in an outpatient or other ambulatory facility.

A new patient visit is limited to one every three years, per patient, per provider.

An established patient is one who has not received professional services from a physician or more than one physician of the same specialty within the same group practice within the last three years. Providers may use procedure codes 1-99211, 1-99212, 1-99213, 1-99214, and 1-99215 when submitting claims for established patient services provided in the office or in an outpatient or other ambulatory facility.

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

Modifier 25 may be used to describe circumstances in which an office visit was provided at the same time as other separately identifiable services. Modifier 25 may be included with the evaluation code when the services rendered are provided for different diagnoses or are performed for different reasons. Both services must be documented as distinct and documentation must be maintained in the medical record and made available to the Texas Medicaid Program upon request.

If an established patient visit is submitted with the same date of service as a new patient visit in any setting by the same provider for any diagnosis, the established patient visit is denied as part of another procedure on the same day. New or established patient care visits are limited to one per day for the same provider regardless of diagnosis.

Office visits (1-99201, 1-99202, 1-99203, 1-99204, 1-99205, 1-99211, 1-99212, 1-99213, 1-99214, and 1-99215) provided on the same day as a planned procedure (minor or extensive), are included in the cost of the procedure and are not considered for reimbursement separately. An office visit provided for a separately identifiable service on the same day as a planned procedure is considered for reimbursement with medical documentation. The modifier 25 should be included with the E/M code to indicate that the evaluation was provided for a separately identifiable service.

Procedures that are included in E/M services are denied as part of another procedure when submitted with the same date of service, by the same provider, as an office visit (1-99201, 1-99202, 1-99203, 1-99204, 1-99205, 1-99211, 1-99212, 1-99213, 1-99214, and 1-99215) or outpatient consultation visit (3-99241, 3-99241, 3-99241, 3-99241, and 3-99245).

Charges for inconvenience or after hours services (1-99050, 1-99056, or 1-99060), by emergency department-based physicians or emergency department-based physician groups are not allowed.

Preventive health visits are available to clients from birth through 20 years of age through THSteps medical check ups. For clients 21 years of age and older, breast exams and Pap smears are available through programs related to women's health, including Texas Medicaid Program family planning services and the Women's Health Program.

A consultation is an E/M service provided at the request of another provider for the evaluation of a specific condition or illness. To be considered for reimbursement as a consultation, the service must meet the following criteria:

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The referring provider must request the evaluation of a particular condition or illness in writing.

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The consulting provider must communicate his medical findings in writing with the referring provider.

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During a consultation, the consulting provider may initiate diagnostic and therapeutic services if necessary. If treatment is initiated and the patient returns for follow up care, an established patient visit should be submitted.

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The medical records maintained by both the referring and consulting providers must identify their counterpart and the reason for the consultation.

Note: If the purpose of the referral is to transfer care, the service is not considered a consultation and may not be submitted for reimbursement as such.

Providers may use procedure codes 3-99241, 3-99242, 3-99243, 3-99244, and 3-99245 when submitting claims for a new or established patient consultation provided in the office or in an outpatient or other ambulatory facility.

Note: An initial psychiatric examination (procedure code 1-90801) is denied as part of another service when procedure codes 3-99241, 3-99242, 3-99243, 3-99244, and 3-99245 are submitted by the same provider within 30 days of the initial psychiatric examination.

An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who require immediate medical attention. The facility must be available to provide services 24 hours per day, 7 days a week.

According to federal legislation (Emergency Medical Transportation and Labor Act), if any individual arrives at the hospital emergency department requesting an examination or treatment, the hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists. The following definitions were developed to be consistent with CMS:

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Antidumping Statute. A hospital must provide to any person who seeks emergency services an appropriate medical screening examination sufficient to determine whether he or she has an emergency medical condition.

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Emergency Medical Condition. A medical condition is considered an emergency when it manifests itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical care could result in one of the following circumstances:

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Placing the patient's health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

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Emergency Services. Services are considered emergency services when hospital-based emergency department services are needed to evaluate or stabilize an emergency medical condition and/or emergency behavioral health condition.

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Medical Screening Examination. The process required to determine, with reasonable clinical confidence, that an emergency medical condition or an emergency behavioral health condition exists. The medical screening examination ranges from a brief history and physical examination to performing ancillary studies and procedures (such as, but not limited to, lumbar punctures, clinical laboratory tests, and computed tomography [CT] scans); the level of care depends on the patient's presenting symptoms. A medical screening examination is not an isolated event; it is an ongoing process. The medical records must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized or appropriately transferred. There should be evidence of whether the patient is stable or unstable.

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No Prior Authorization Before Screening or Stabilization. It is not appropriate for a hospital to request or a health plan to require prior authorization before the patient has received a medical screening examination to determine the presence or absence of an emergency medical condition or before the patient's emergency condition is stabilized.

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Post-Stabilization Services. In the case of an emergency medical condition or emergency behavioral health condition, post-stabilization services begin once the patient has been determined stable by the emergency department physician or discharged, transferred, or admitted to the hospital.

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Routine Condition. A health condition, including a behavioral health situation, is considered routine when it can be addressed by a routine office visit within the next several days after the emergency department visit.

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Stabilization Services. In the case of an emergency medical condition or an emergency behavioral health condition, to stabilize is to provide medical services to assure within reasonable medical probability that no deterioration of the condition is likely to result from or occur during discharge, transfer, or admission of the patient from the emergency department.

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Triage. The evaluation, by a nurse(s), of people presenting for health care to a medical facility that allows treatment of the most serious cases first.

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Urgent Behavioral Health Situations. Conditions that require attention and assessment within 24 hours but that do not place the patient in immediate danger to themselves or others, and the patient is able to cooperate with treatment.

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Urgent Condition. A health condition, including an urgent behavioral health situation, is considered urgent when it is not an emergency but is severe or painful enough to require medical treatment, evaluation, or treatment within 24 hours by a physician to prevent serious deterioration of the patient's condition or health.

Emergency department procedure codes are used to describe E/M services provided in the emergency department to new or established patients. Physicians may use procedure codes 1-99281, 1-99282, 1-99283, 1-99284, and 1-99285 when submitting claims for emergency department services provided in the emergency department.

If an emergency department visit is submitted with the same date of service, by the same provider, as an office visit, outpatient consultation, or nursing facility service (1-99304, 1-99305, 1-99306, 1-99307, 1-99308, 1-99309, and 1-99310) the emergency department visit may be considered for reimbursement and the office, consultation, and/or nursing facility visit is denied.

Emergency department visits are denied when submitted with the same date of service as an observation service (1-99217, 1-99218, 1-99219, and 1-99220) by the same provider.

Multiple emergency department visits on the same day, submitted by the same provider, must have the times for each visit documented on the claim form. More than one visit on the same day can also be indicated by adding the modifier 76 to the claim form. Medical documentation is required to support the charge of more than one emergency department visit with the same date of service.

Critical care provided on the same day as an emergency room visit may be submitted when the services are rendered during a separate encounter. Medical documentation is required to support the charge of critical care and emergency room visit with the same date of service.

Reimbursement for physicians in the emergency department is based on Section 104 of TEFRA. TEFRA requires that Medicaid limit reimbursement for those physicians' services furnished in hospital outpatient settings that also are ordinarily furnished in physician offices. The diagnoses list of emergent conditions is used to determine the appropriate reimbursement for these services. The reimbursement for each service is determined by establishing a charge base for each professional service and multiplying the charge base by 60 percent.

Texas Medicaid limits reimbursement for after-hours charges to office-based providers rendering services after routine office hours.

An office-based provider may submit an after-hours charge in addition to a visit for providing services after his routine office hours. This should be submitted when a provider, in his clinical judgment, deems it medically necessary to interrupt his schedule to care for a patient with an emergent condition. A provider's routine office hours are those hours posted at the physician's office as the usual office hours. Medicaid reimburses office-based physicians an inconvenience charge when any of the following exists:

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The physician leaves the office or home to see a client in the emergency room.

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The physician leaves the home and returns to the office to see a client after the physician's routine office hours.

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The physician is interrupted from routine office hours to attend to another client's emergency outside of the office.

Providers may use procedure codes 1-99050, 1-99056, and 1-99060 to submit claims for services outside of business hours.

Hospital observation services (procedure codes 1-99217, 1-99218, 1-99219, and 1-99220) are professional services that span a period of more than 6 hours but less than 24 hours regardless of the hour of the initial contact and regardless of whether or not the patient remains under physician care past midnight.

Observation may take place in any patient care area of the hospital or outpatient setting.

Observation care discharge day management procedure code 1-99217 may be submitted to report services provided to a patient upon discharge from "observation status" if the discharge is after the date of admission. The following procedure codes are denied if submitted with the same date of service as procedure codes 1-99217, 1-99234, 1-99235, and 1-99236:


Procedure Codes
1-99211	1-99212	1-99213
1-99214	1-99215	1-99218
1-99219	1-99220

E/M services provided in any POS other than the inpatient hospital and submitted with the same DOS as a physician observation visit, by the same provider, is denied.

If a physician observation visit (procedure codes 1-99217, 1-99218, 1-99219, 1-99220, 1-99234, 1-99235, and 1-99236) is submitted with the same date of service as prolonged services (procedure codes 1-99354 and 1-99355) by the same provider, the prolonged services are denied as part of another procedure on the same day.

If dialysis treatment and physician observation visits are submitted with the same date of service by the same provider and the provider identifiers used indicate the same specialty (other than nephrology or internal medicine), the dialysis treatment is paid and the physician observation visit is denied.