Services from the Medicine Section of CPT 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 information below does not include information about Injections and Intravenous Infusion Billed with Other Services or Immunization Administration Billed with Other Services which are addressed separately.

The following code edits apply to codes from the Medicine section of CPT.

Medicine section codes billed with office visits, outpatient consultations and hospital-based visits

When billing for visits and consultations with codes from the Medicine section of CPT it is important to bill accurately. In some cases, a modifier code must be appended to the visit/consultation 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 in the following policies:

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

Medicine section codes to which the above information applies:

Note: The above lists are not all inclusive, but represent codes from the E/M section of CPT that are most commonly billed with codes from the Medicine section and to which these guidelines apply:

Medicine section codes billed with codes from the Surgery sections of CPT

The code edits listed below represent codes from the Medicine section of CPT that may be billed with codes from the Surgery section. If the code from the left column is billed with any of the codes in the right column, one of the codes will deny. Reasons for denials vary and include:

• The codes may be mutually exclusive. Mutually exclusive procedures are two or more procedures that are usually not performed during the same patient encounter on the same date of service
• Multiple codes may have been billed, which taken together are more accurately described by a more comprehensive procedure code.
• The code may be incidental to another code. An incidental procedure is a procedure carried out at the same time as a more compels primary procedure; however, the incidental procedure requires little additional physician resources and/or is clinically integral to the performance.

However, unless otherwise indicated, a modifier may be used to request separate payment, if criteria for the use of the modifier are met. Applicable modifiers may include 51, 58, 59, 76, 78, 79, LT, RT and other site specific modifiers. Practitioners are urged to familiarize themselves with the criteria listed in CPT and in the following policies.

• Modifier Codes XE, XP, XS, XU and 59
• Modifier Code 76
• Modifier Codes 78 and 79
• Multiple Surgical Procedures

Codes to which the above information applies:

Note: The above list is not all inclusive and is subject to change.

Medicine section codes billed with codes from the Radiology section of CPT

When billing for services from the Medicine section along with services from the Radiology section, it is important to bill accurately. In some cases modifiers may be needed to clarify the services rendered. Modifiers that may be used include TC, 26, 59, 76, 77, LT, RT and other site-specific modifiers. Practitioners are urged to familiarize themselves with the criteria listed in CPT and in the following policies.

• Modifier Codes XE, XP, XS, XU and 59
• Modifier Code 76
• Radiology and Nuclear Medicine – Coding Guidelines

Codes to which the above information applies:

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

Revision History