Date:
To:
From:
Subject:
September 30, 2014
All Participating Health Care Professionals Rochester, Finger Lakes and Southern Tier Region
Monroe Plan Provider Relations Department
Clinical Editing Policy - Evaluation and Management Coding
The Centers for Medicare & Medicaid Services has identified Evaluation and Management (E/M) coding as
an area that has significant opportunity for increased accuracy. Effective with dates of service on and after
January 1, 2015, Monroe Plan for Medical Care and Excellus BlueCross BlueShield will adjust the level of E/M codes when
appropriate.
Our Recovery Audit Program began auditing levels of E/M codes, and we have found a high incidence of over coding for
certain E/M services. As a result, we have developed a program with a strong clinical and statistical methodology to address
these billing issues.
Diagnosis codes will be used in determining the appropriate E/M level, using all diagnoses on the claim. If the diagnosis
codes submitted do not support the level of E/M billed, the E/M code will be automatically adjusted to 1 or 2 levels lower at
the time of adjudication based on the diagnosis code allowing the highest level.
This policy is eligible for a clinical editing dispute.
E/M codes eligible for adjustment (code descriptions provided on the reverse of this bulletin)


99204-99205
99214-99215
Example #
1
BILLED E/M CODE
99215
ICD-9 DIAGNOSIS CODE
401.01
2
99215
402.01

99284-99285
RESULT
99215 is adjusted to 99213
99215 will not be adjusted to
another E/M code
We recommend that you carefully document each service provided and bill all appropriate diagnosis codes, according to
CMS guidelines. You can access The Documentation Guidelines for Evaluation and Management via the CMS website at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf
Please share this important bulletin with your front-office and billing staff, and with any other practice locations you have.
If you have questions regarding this information, please contact Monroe Plan at (585) 244-5550 or (800) 724-4658.
1120 Pittsford-Victor Road
Pittsford, New York 14534
(585) 244-5550 (800) 724-4658
FAX: (585) 244-9647
CPT®-4 2014 CODE DESCRIPTIONS:
99203
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A
detailed history; A detailed examination; Medical decision making of low 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 severity. Typically, 30
minutes are spent face-to-face with the patient and/or family.
99204
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A
comprehensive history; A comprehensive 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, 45 minutes are spent face-to-face with the patient and/or family.
99205
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A
comprehensive history; A comprehensive examination; Medical decision making of high 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, 60 minutes are spent face-to-face with the patient and/or family.
99213
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3
key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making
of low complexity. Counseling and 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 low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or
family.
99214
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3
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.
99215
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3
key components: A comprehensive history; A comprehensive examination; Medical decision making of high 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, 40 minutes are spent face-to-face with the patient and/or family.
99283
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An
expanded problem focused history; An expanded problem focused examination; and 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 severity.
99284
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A
detailed history; A detailed examination; and 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 high severity, and
require urgent evaluation by the physician or other qualified health care professionals but do not pose an immediate significant
threat to life or physiologic function.
99285
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the
constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A
comprehensive examination; and Medical decision making of high 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 high severity and pose an immediate
significant threat to life or physiologic function.
ICD-9-CM CODE DESCRIPTIONS:
401.01 Essential hypertension; benign
402.01 Hypertensive heart disease; malignant; with heart failure
1120 Pittsford-Victor Road
Pittsford, New York 14534
(585) 244-5550 (800) 724-4658
FAX: (585) 244-9647