Office Visits Billed with Other Services

The code edit changes described in the guidelines below will not override HMSA’s existing medical policies.

The edits described below apply to claims processed under the new claims processing system. Nevertheless, HMSA suggests that practitioners adopt the guidelines when filing claims to HMSA for all private business claims.

The following code edits apply to office visits (CPT codes 99201 - 99205 and 99211 - 99215) billed with other services.

Modifiers

When billing office visits with other services it is important to bill accurately. In some cases, a modifier code must be appended to the office visit code to ensure that both services are paid when appropriate. The following modifiers may be used for this purpose: 24, 25 and 57. Practitioners are urged to familiarize themselves with the criteria listed in CPT and the following policies.

• Modifier Code 25
• Modifier Code 57
• Preoperative Visits
• Postoperative Visits

Modifier codes should only be used when the service meets the criteria described in CPT and the policies. HMSA will perform postpayment reviews of modifier usage as needed to verify modifiers were used as described. If postpayment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.

Specific edits

Surgery section

If an established patient office visit (99211 - 99215) is done in conjunction with any service listed in the Surgery section of CPT (codes 10041 - 69990), and the office visit service meets criteria for the use of modifier codes 24, 25 or 57, the appropriate modifier should be appended to the office visit code. Note: The presence of the modifier does not guarantee payment if the modifier is not applicable or other payment policies apply.

The following surgical codes are frequently billed by providers without modifiers when paired with office visits. When these services are billed, if the appropriate modifier is not appended to the office visit code, the office visit may not be paid.

1. When one of these procedures is billed, HMSA’s old claims processing system will allow payment only of the higher-valued code, either the visit or procedure. Under the new system, both may be paid if criteria are met.
2. A modifier should be used when this service is billed with either an established patient visit or a new patient visit.

Note: The list above is not all inclusive, but represents codes from the Surgery section that are most commonly billed with an office visit and to which these guidelines apply.

Medicine section

For information about office visits billed with the administration of immunizations, see Immunization Administration Billed with Other Services. For information about office visits billed with the administration of injections, see Injections and Intravenous Infusion Billed with Other Service.

If an office visit is done in conjunction with other services from the Medicine section of CPT (codes 90281 - 99602), and the office visit service meets criteria for the use of modifier code 25, this modifier should be appended to the office visit code. If the modifier is not appended, the office visit may not be paid.

When one of the following codes is billed together with an office visit, and the visit meets criteria for the use of modifier 25, modifier 25 should be appended to the visit code. Note: The presence of the modifier does not guarantee payment if the modifier is not applicable or other payment policies apply.

Note: The list above is not all inclusive, but represents the codes in the Medicine section that are most commonly billed with an office visit and to which these guidelines apply.

Revision History