Evaluation and Management Services

Use of Current Procedural Terminology Codes

Medicare will pay for evaluation and management (E/M) services for a nurse practitioner (NP), clinical nurse specialist (CNS) or certified nurse-midwife (CNM) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners (NPPs). The service provided must be medically necessary and the service must be within the scope of practice for the NPP in the state in which he or she practices.

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a Current Procedural Terminology (CPT) code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

CPT only copyright 2007 American Medical Association. All Rights Reserved.