CPT CODE AND Description


Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.

• Physicians should us CPT code 99499 with modifier SC V07.31 (medically necessary service).

• The procedure includes and oral evaluation, risk assessment, diagnosis code 521.01, parental counseling, application of varnish and a referral to a dentist.

• The fluoride varnish procedure may be billed once every 3 months up to age 42 months.

• Procedure code 99499 SC V07.31 reimburses physicians, ARNPs, and Pas $27.00

• The procedure may be submitted once per claim on the same date of service as other procedures.

• Fluoride varnish may also be applied to a child’s teeth at the time of the Child Health Check-Up visit. It can also be billed with procedure code 99499 SC, as noted above.

• If a child comes to the office for immunizations, the oral evaluation and fluoride varnish can be provided during the same visit and billed using 99499 SC 07.31 in addition to the immunizations service.

• CHIP and Medikids are eligible for this service.

Modifier usage with CPT 99499

Modifier -57 is reported with an E/M code to indicate the day the decision to perform a major surgery was made. Turn to Appendix A in the CPT manual and read the description of this modifier. Modifier -57 can be reported not only with E/M codes (99201-99499) to indicate the initial decision to perform a procedure or service but also with the ophthalmologic codes (92002-92014) located in the Medicine section. Modifier -57 requests payment for an E/M service outside of the global package for a major procedure when the decision to perform the surgery was made during the E/M service.

At the present time, not all modifiers are recognized by all thirdparty payers. Some third-party payers have agreed to pay a physician separately from the surgical package for the initial evaluation of a condition during which the decision to perform surgery was made. Modifier -57 is used to let the payer know that payment for this initial evaluation should be made in addition to payment for surgery.

E/M services provided the day before or the day of a major surgery are included in the global package. There are some exceptions, such as when the service is the patient’s initial visit to the physician. To receive payment for these initial visits, modifier -57 is reported to indicate the decision for surgery was made the day before or the day of the major procedure and modifier -25 is used to indicate the day of a minor procedure.

Other evaluation and management services

Other Evaluation and Management Services (99499) is the last subsection in the E/M section. Code 99499 is an unlisted code that is used to indicate that there is no other code that accurately represents the services provided to the patient. A special report would accompany the unlisted E/M service code. 99499 should be reported if the key components of an E/M service do not meet the lowest level of a category (e.g., 99221)

Hospital Observation Services

• If the documentation does not support the minimum requirements for codes 99218-99220, 9921-99223 or 99234- 99236 then report the Unlisted E/M Service code (99499)

• When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission – Contractors pay the office visit as billed and the Level 1 initial hospital care code

• Currently, there are no CPT® instructions on how to code hosp p ital observation services provided on more than two dates (ie, a patient is admitted to
observation status at 8:00 PM on March 1, continues to be observed on March 2, and is discharged from observation status on March 3 at 1:00 PM)

• CPT® Assistant advised using the unlisted E/M service code 99499 for March 2

Evaluation and Management – CPT codes (99201-99499); E&M codes are used to report services to new and established patients in the office or other outpatient facility. Additionally, any therapeutic services that are billed by CPs under CPT psychotherapy codes that include medical evaluation and management services are not covered. Psychologists cannot bill E&M codes when treating Medicare beneficiaries because CMS currently restricts the use of these codes. CMS has taken the position that E&M codes involve services unique to medical management, such as medical diagnostic evaluation, drug management, and interpreting laboratory or other medical diagnostic studies. Psychologists treating patients with private insurance may be able to bill for E&M services because not all insurers impose the same restrictions as Medicare. Psychologists should check with the private carrier to determine its policy on E&M services. Therapeutic services that are billed by CPs under CPT psychotherapy codes that include medical evaluation and management services are not covered.

Online evaluation and management (online digital evaluation and management) services for new patients should be reported with an unlisted evaluation and management code (CPT® 99499) appended with modifier -GT, and place of service code 02 to indicate the telehealth service. Please note that CPT® 99421-99423 for online digital evaluation and management service and G2061-G2063 for nonphysician professional online assessment should be reported only for established patients.