Q2. Under Plan N, what constitutes an "office visit" for purposes of determining whether the subscriber is subject to the Part B coinsurance or copayment of up to $20?
Services coded as office visits or evaluation and management visits and billed on Part B professional claim forms (CMS-1500 or ASC X12N 837 professional) would be considered “office visits” for purposes of determining whether the subscriber is subject to the Plan N Part B coinsurance or copayment of up to $20. These include CPT-4 codes 99201 – 99205 and 99211 – 99215, as well as 92002, 92004, 92012, and 92014 (ophthalmology) and 90805 (psychotherapy).
Q3. When applying the Plan N physician office copayment or coinsurance, should the amount be applied only to the office visit charge and not to other charges such as laboratory, x-ray or durable medical equipment (DME)?
The coinsurance or copayment should be applied only to CPT-4 codes 99201 – 99205 and 99211 – 99215, which are codes used to bill an office visit.
Reference:
https://www.cms.gov/Medicare/Health-Plans/Medigap/downloads/Plan_N_Guidance2.pdf