Q/A: Why is Code 99080 Being Denied when Billed with an E/M Service?

by  Wyn Staheli, Director of Content - innoviHealth
Mar 21st, 2018 - Reviewed/Updated Jan 30th

To properly answer the question, it is important to first review the requirements of selecting the appropriate level of Evaluation and Management (E/M) service and how that relates to reporting a 99080 special report service.

Every CPT code has both performance and reporting (documentation) requirements. The level of an Evaluation and Management (E/M) service is determined based on the amount of key components performed or time spent counseling and coordinating care AND also includes the documentation that describes what was done. For an established E/M service, performance of 2 of the 3 key components (History, Exam, Medical Decision Making) is required or, if based on time, the performance portion is determined based on the length of the face-to-face time the provider spent with the patient and what was counseled and/or coordinated (separate from the time spent performing the key components).

Reporting or documentation is the second requirement. It is retained in the medical record as proof the service was performed. If the level of E/M service was based on the key components, those key components should be adequately documented to support the level of service. If the level of E/M service was based on counseling and/or coordination of care, then the face-to-face time should be documented along with a summary of what was discussed or coordinated as proof the service was performed and to support correct code selection. If both key components and counseling and coordination of care were performed in the E/M service, the provider must document both, then determine which (components or time), dominated the service. Remember that time can only dominate a service if more than 50% of the total time spent face-to-face with the patient was spent performing the counseling and/or coordination of care.

The need for a "special report," as noted in 99080, in addition to the E/M service, should be based on a payer requirement that the provider submits a separate report, above and beyond the information documented in the E/M encounter. If the provider produces a special report which serves as the report (documentation) for both the 99080 and the E/M encounter, this would be considered double dipping or getting paid twice for the same work (fraud). Additionally, if the E/M record contains the information needed to justify the level of E/M provided, but the provider creates a special report anyway, based on information already contained in the E/M service, and charges separately for it, this, too, could be construed as fraud, potentially opening the provider to further scrutiny.

Although the payer considers 99080 to be a covered code, there may be payer-specific rules and regulations that govern payment for it, especially when performed at the same encounter as an E/M service. If the payer requires a special report, above and beyond what is required for documentation in the E/M service, then reporting 99080 should be considered. "Above and beyond" signifies that the work required to create the special report would be work that is NOT usual and customary to the performance of an E/M established patient visit. Always keep in mind that the medical record should easily reflect the performance and reporting of each individual service being billed as separate and individual services.