office visit follow up cpt code

Getting clear on the new coding rules can help you eliminate bloated documentation and improve reimbursement to reflect the value of your visits.

THOMAS WEIDA, MD, FAAFP, AND JANE WEIDA, MD, FAAFP

Fam Pract Manag. 2022;29(1):26-31

Author disclosures: no relevant financial relationships.

In 2021, significant changes were adopted for the documentation guidelines for outpatient evaluation and management (E/M) visit codes. Most notably, medical decision making or time became primary drivers of visit level selection, rather than the number of history and physical exam bullets.

In this article, we review the context for these changes, describe them briefly, and offer a quick reference tool to help physicians apply the new rules in practice.

The revisions to the E/M outpatient visit codes reduced administrative burden by eliminating bullet points for the history and physical exam elements.

Code level selection is now simplified — based on either medical decision making or total time.

The authors' one-page coding reference tool can help simplify the new rules.

HOW WE GOT HERE

In the 2019 Medicare physician fee schedule final rule, released in November 2018, the Centers for Medicare & Medicaid Services (CMS) adopted revisions to the outpatient E/M codes in order to reduce administrative burden. (See https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year .) Originally scheduled for implementation in 2021, these changes would have combined visit levels 2–4 into a blended payment rate (e.g., one rate for 99202-99204 and one rate for 99212-99214), among other changes.

In response, the American Medical Association (AMA) convened a joint CPT Editorial Board and Relative Value Scale Update Committee (RUC) workgroup to build on the changes and propose some alternatives. The workgroup's goals were to decrease administrative burden, payer audits, and unnecessary medical record documentation while ensuring that payment of E/M services is resource-based.

The workgroup approved significant revisions to the outpatient office visit E/M codes. Code 99201 was deleted. The history and/or physical examination and the counting of bullets were eliminated as components for code selection (although history and/or physical examination documentation should still be performed as medically appropriate). Medical decision making (MDM) or time could be used for code level selection. Changes were made to the code descriptors for 99202-99205 and 99211-99215, the definition of medical decision making, and the calculation of time, and a shorter prolonged services add-on code was created. CMS adopted these new E/M coding guidelines. As a result of the changes to medical decision making and time-based coding, the RUC revised the 2021 relative value units (RVUs) for office visit E/M codes. Most of the values increased, yielding an overall increase of more than 10%.

CODING BASED ON MEDICAL DECISION MAKING

For outpatient E/M coding, medical decision making now has three components:

Number and complexity of problems addressed at the encounter,

Amount and/or complexity of data to be reviewed and analyzed,

Risk of complications and/or morbidity or mortality of patient management.

There are four levels of decision making for each of these components: straightforward, low complexity, moderate complexity, and high complexity.

To determine the level of code for a visit, two of the three components must meet or exceed that level of coding. ( See the table .) For example, if the patient has multiple problems addressed at the encounter, but the data is limited and the risk of complications is low, then the level of medical decision making would be low. New patient codes 99202-99205 and established patient codes 99212-99215 use the same components and levels of decision making for code selection.

Determining medical decision making usually starts with identifying the number and complexity of problems addressed and then determining the data or risk components that support that medical decision making. If a second component does not meet or exceed the problem component, then a lower level of decision making is appropriate. The set of tables below illustrate the essential concepts of these code levels. Each level has specific criteria for each component.

Straightforward medical decision making: Codes 99202 and 99212 include one self-limited or minor problem with minimal or no data and minimal risk.

An example of a 99202 or 99212 is an otherwise healthy patient with cough and congestion due to the common cold.

Low complexity medical decision making: Codes 99203 and 99213 include two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury.

The data component requires one of two categories to establish the level. Category 1 data requires at least two items in any combination of the following: each unique source's prior external notes reviewed, each unique test result reviewed, or each unique test ordered. Tests include imaging, laboratory, psychometric, or physiologic data. A clinical lab panel, such as a complete blood count, is a single test. Of note, if a test is ordered, the review of that test is included with the ordering, even if the review is done at a subsequent visit. Tests ordered outside of an encounter may be counted in the encounter in which they are analyzed. Category 2 data includes significant history given by an independent historian. Parents giving the history for their child is a typical example.

The risk component is low. There is low risk of morbidity from additional diagnostic testing or treatment.

An example of a 99203 or 99213 is a sinus infection treated with an antibiotic. Although the prescription makes the risk component moderate, the one acute uncomplicated illness is a low-complexity problem, and there are no data points.

Moderate complexity medical decision making: Codes 99204 and 99214 include two or more stable chronic illnesses, one or more chronic illnesses with exacerbation, progression, or side effects of treatment, one undiagnosed new problem with uncertain prognosis, one acute illness with systemic symptoms, or one acute complicated injury. A patient who is not at a treatment goal, such as a patient with poorly controlled diabetes, is not stable. Systemic general symptoms such as fever or fatigue in a minor illness (e.g., a cold with fever) do not raise the complexity to moderate. More appropriate would be fever with pyelonephritis, pneumonitis, or colitis.

The data component requires one of three categories to establish the level. Category 1 data requires at least three items in any combination of the following: each unique source's prior external notes reviewed, each unique test result reviewed, each unique test ordered, or independent historian involvement. Physicians cannot count tests that they or someone of the same specialty and same group practice are interpreting and reporting separately (e.g., electrocardiogram, X-ray, or spirometry). Category 2 data includes the independent interpretation of a test performed by another physician/other qualified health care professional (QHP) (not separately reported). For instance, if a chest X-ray was ordered and the ordering clinician included the interpretation in the visit documentation, this would qualify for data point Category 2. However, if the ordering clinician bills separately for the interpretation of the X-ray, then that cannot be used as an element in this category and would be an element for Category 1. Category 3 data includes discussion of management or test interpretation with an external physician/QHP (not separately reported).

The risk component may include prescription drug management, a decision for minor surgery with patient or procedure risk factors, a decision for elective major surgery without patient or procedure risk factors, or social determinants of health (SDOH) that significantly limit diagnostic or treatment options, such as food or housing insecurity. For prescription drug management, renewing pre-existing chronic medications would qualify. Documentation that the physician is managing the patient for the condition for which the medications are being prescribed would help establish validity in the use of this criterion for MDM.

An example of a 99204 or 99214 is a patient being seen for follow-up of hypertension and diabetes, which are well-controlled. An example using SDOH would be a patient with chronic knee pain and a positive anterior drawer test who needs imaging of the knee but cannot afford this care. Documenting that the patient cannot afford to obtain an MRI of the knee at this time, which significantly limits your ability to confirm the diagnosis and recommend treatment, adds to the risk component.

High complexity medical decision making: Codes 99205 and 99215 include one or more chronic illnesses with a severe exacerbation, progression, or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function.

The data component requires two of three categories to establish the level. These data categories are the same as those for 99204 and 99214, and they follow the same rules.

The risk component may include drug therapy requiring intensive monitoring for toxicity. Decisions regarding elective major surgery with patient or procedure risk, emergency major surgery, hospitalization, or “do not resuscitate” orders are also high risk. Intensive prescription drug monitoring is typically supported by a laboratory test, physiologic test, or imaging, and is done to evaluate for complications of the treatment. It may be short-term or long-term. Long-term monitoring is at least quarterly. An example would be monitoring for cytopenia during antineoplastic therapy. Monitoring the therapeutic effect of a treatment, such as glucose monitoring during insulin therapy, is not considered intensive prescription drug monitoring.

An example of a 99205 or 99215 is a patient with severe exacerbation of chronic heart failure who is admitted to the hospital.

CODING OUTPATIENT E/M VISITS

Time-based coding.

An alternative method to determine the appropriate visit level is time-based coding. A major change is that total time now includes both face-to-face and non-face-to-face services personally performed by the physician/QHP on the day of the visit. Additionally, time-based coding is no longer restricted to counseling services. Instead, it includes the following:

Preparing to see the patient (e.g., reviewing external test results),

Obtaining and/or reviewing separately obtained history,

Performing a medically appropriate examination and/or evaluation,

Counseling and educating the patient, family, or caregiver,

Ordering medications, tests, or procedures,

Referring and communicating with other health care professionals (when not separately reported),

Documenting clinical information in the electronic or other health record,

Independently interpreting results (not separately reported with a CPT code) and communicating results to the patient, family, or caregiver.

Care coordination (not separately reported with a CPT code).

Time spent by clinical staff cannot count toward total time. However, time spent by another physician/QHP (not a resident physician) in the same group can be included. If a nurse practitioner performs the initial intake and the physician provides the assessment and plan, both of those times can be counted, although only one person's time can be counted while they are discussing the case with each other. The visit should be billed under the clinician who provided the substantive portion (more than half) of the time, although both clinicians need to be identified in the medical record. Time spent must be documented in the note. It is advisable to specifically document the time spent and the activities performed both face-to-face and non-face-to-face.

The amount of total time required for each level of coding changed under the new time-based coding guidelines. (See the “Total time ” table.)

PROLONGED VISIT CODES

When time on the date of service extends beyond the times for codes 99205 or 99215, prolonged visit codes can be used. The AMA CPT committee developed code 99417 for prolonged visits, and Medicare developed code G2212. These are added in 15-minute increments in addition to codes 99205 or 99215. Code G2212 can be added once the maximum time for 99205 or 99215 has been surpassed by a full 15 minutes, whereas code 99417 can be added once the minimum time for 99205 or 99215 has been surpassed by a full 15 minutes. Less than 15 minutes is not reportable. Multiple units can be reported. Prolonged visit codes cannot be used with the shorter E/M levels, i.e., 99202-99204 and 99212-99214. (See “Prolonged services ” tables.) Clinicians should consult with individual payers to determine which code to use — G2212 or 99417.

SIMPLIFIED CODING AND DOCUMENTATION

The revisions to the outpatient E/M visit codes reduced administrative burden by eliminating bullet points for the history and physical exam elements. Only medically appropriate documentation is required. Code level selection is simplified — based on either medical decision making or total time. By applying these changes, primary care clinicians can eliminate bloated documentation and improve reimbursement reflecting the value of the visit.

Continue Reading

More in FPM

CPT 99211, 99212, 99213, 99214, 99215 – Established patient office visit

CPT CODE and Description

CPT 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. Billing Instructions: Bill 1 unit per visit.

CPT 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting Problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit. CPT 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-toface with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:

1. History 2. Examination 3. Medical decision-making.

When billing office or other outpatient services for established patients, two of the three key components must be fully documented in order to bill (other than 99211). When counseling and/or coordination of care dominates (more than 50 percent) the physician patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Current Procedural Terminology (CPT) codes and requirements

99211 – 5 minutes (average)

• Patient presenting with minimal problems • Three components not required

99212 – 10 minutes (average)

• Problem focused history. Documentation needed: • Chief complaint • Brief history of present illness • Problem focused examination. Documentation needed: • Limited examination of the affected body area or organ system • Medical decision making that is straightforward. Documentation needed (two of three below must be met or exceeded): • Minimal number of diagnoses or management options • None or minimal amount and/or complexity of data to be reviewed • Minimal risk of significant complications, morbidity and/or mortality

99213 – 15 minutes (average)

• Expanded problem focused history. Documentation needed: • Chief complaint • Brief history of present illness • Problem pertinent review of systems • Expanded problem focused examination. Documentation needed: • Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s) • Medical decision making that is of low complexity. Documentation needed (two of three below must be met or exceeded): • Limited number of diagnoses or management options • Limited amount and/or complexity of data to be reviewed • Low risk of significant complications, morbidity and/or mortality

99214 – 25 minutes (average)

• Detailed history. Documentation needed: • Chief complaint • Extended history of present illness • Extended review of systems • Pertinent past, family and/or social history • Detailed examination. Documentation needed: • Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s) • Medical decision making that is of moderate complexity. Documentation needed (two of three below must be met or exceeded): • Multiple number of diagnoses or management options • Moderate amount and/or complexity of data to be reviewed • Moderate risk of significant complications, morbidity and/or mortality

99215 – 40 minutes (average) • Comprehensive history. Documentation needed: • Chief complaint • Extended history of present illness • Complete review of systems • Complete past, family, and social history • Comprehensive examination. Documentation needed: • A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or eight or more organ system(s) • Medical decision making that is of high complexity. Documentation needed (two of three below must be met or exceeded): • Extensive number of diagnoses or management options • Extensive amount and/or complexity of data to be reviewed

• High risk of significant complications, morbidity and/or mortality An important guideline to remember when reporting office visits other than counseling and coordination of care is that only two of the three key components must be reported.

The following is a summary of the requirements for codes 99211 – 99215.

99211: 5 minutes and may not require the presence of a physician 99212: 10 minutes A problem focused history A problem focused examination Straight forward decision making 99213: 15 minutes An expanded problem focused history An expanded problem focused examination Medical decision making of low complexity 99214: 25 minutes A detailed history A detailed examination Medical decision making of moderate complexity

99215: 40 minutes A comprehensive history A comprehensive examination Medical decision making of high complexity

History and physical examination skills and documentation guidelines we were taught in medical training tend to produce a very high quality of medical care. But these do not always meet the guidelines in the multiple medical record components that are required by CPT coding system for E/M coding. To be more efficient and improve reimbursements, physicians must have a better understanding of the Current Procedural Terminology requirements. Future discussions in this section of the AHS website will include a comprehensive discussion of the three key components of CPT coding: History, Examination, and Medical Decision Making, as well as a review of the importance of understanding the Nature of the Presenting Problem in ensuring proper coding. The fourth quarterly future topic in this series will be devoted to the International Classification of Diseases (ICD – 9-CM) coding.

History type ofpatient type of history details of History new est. HPI ROS other history

99211 M.D. presence not required, minimal problem, typically 5 minute service 99201 99212 problem focused brief (1-3 elements) 99202 99213 exp. prob. focused brief (1-3 elements) prob. pertinent (1 system) 99203 99214 detailed ext. (=4 elements) extended (2-9 systems) pertinent (1 area) 99204 comprehensive ext. (=4 elements) complete (=10 systems) complete (= 2 areas) 99205 99215 comprehensive ext. (=4 elements) complete (=10 systems) complete (= 2 areas)

Examination type ofpatient type of exam details of Examination new est.

99211 exam may not be necessary 99201 99212 problem focused limited – affected area or organ system 99202 99213 exp. prob. focused limited – affected area / organ system + other related / symptomatic areas 99203 99214 detailed extended of affected area / organ system + related / symptomatic areas 99204 comprehensive general multi-system exam or complete exam of single organ system 99205 99215 comprehensive general multi-system exam or complete exam of single organ system Medical Decision Making type ofpatient type of details of Medical Decision Making new est. decision making # of diagnoses / management options amount/complexity of data risk of complications / morbidity / mortality

99211 may not require medical decision making 99201 straightforward minimal minimal minimal 99202 99212 straightforward minimal minimal minimal 99203 99213 low complexity limited limited low 99204 99214 moderate complex. multiple multiple moderate 99205 99215 high complexity extensive extensive high

Note: for new patients, all three key components must meet or exceed the above requirements for a given level of service; for established patients, two of the three key components must meet or exceed the requirements. Details of History Details of Examination HPI elements (8): ROS systems (14): body areas: organ systems: location symptoms (e.g. cough) head, including face constitutional quality eyes neck (vital signs, general)

severity ears/nose/throat/mouth chest, inc. breasts, axillae eyes duration cardiovascular abdomen ears, nose, throat, mouth timing respiratory genitalia, groin, buttocks cardiovascular context gastrointestinal back, including spine respiratory modifying factors genitourinary each extremity gastrointestinal assoc. signs/symptoms musculoskeletal genitourinary integumentary musculoskeletal other history areas neurologic integumentary (req. for 99203/14 & up) psychiatric neurologic past history endocrine psychiatric family history hematologic/lymphatic hematologic/lymphatic social history allergic/immunologic /immunologic

• four additional factors may be considered in determining the appropriate code (level of service) for a visit: 1. nature of the presenting problem (minimal, self-limited/minor, low, moderate, or high severity) 2. coordination of care with other health care professionals * 3. counseling * 4. time – see chart below for “typical” time spent face-to-face with patient/family for the various levels of service 5 min. 10 min. 15 min. 20 min. 25 min. 30 min. 40 min. 45 min. 60 min. new patient 99201 99202 99203 99204 99205 est. patient 99211 99212 99213 99214 99215 * when counseling or coordination of care comprises more than 50% of the visit or service rendered, time is the key factor in determining the appropriate code and the total time spent should be clearly documented.

Frequently asked questions CPT 99213 and 99214

99213 CPT code requirements?

Time – 20-29 minutes of the total time is spent on the date of the encounter

Key Components – Based on MDM alone (2 out of 3 elements). Elements are

Number and complexity of the problem
Amount and/or Complexity of Data to be Reviewed and Analyzed (must meet 1 of the 2 categories)
Risk of Complications and/or Morbidity or Mortality of Patient Management

how often can CPT 99392 be billed?

It can be billed once in a year (at least it should have completed 11 months)

is CPT 99213 covered by medicare?

Yes, covered by Medicare

how often can CPT 99223 be billed?

It can be billed only once per day by the same physician or physicians of the same specialty from the same group of practice.

how often can 99213 be billed?

There is no specific limitation for billing this code

when to use CPT code 99213

Only when the patient is an established patient seen by the same physician of the same specialty from the same group practice

difference between 99213 and 99214?

when to use CPT code 99214?

how often can you bill 99214?

is 99214 covered by medicare?

what is the difference between CPT code 99214 and 99215?

CPT 99214 cost?

Non-facility – $129.77
Facility – $98.97

Patient Status

The status of a patient must be verified for correct coding and billing. There are four categories:

1. New: A new patient is someone who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.

2. Established: An established patient is someone who has received any professional service from a physician in group or same specialty within the past three years.

1. New patients, consultations, inpatient and emergency room visits MUST have all three key components (e.g., History, Examination and Medical Decision Making) to meet an E/M level of service.

2. Established patients and subsequent inpatient visit MUST have two out of three key components (e.g., History, Examination and Medical Decision Making) to meet the appropriate level of E/M service.

Time can be the controlling factor to qualify for a particular level of E/M visit. This can occur when counseling and/ or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face in the office or outpatient setting, floor/unit time in the hospital or nursing facility). For example, if 25 minutes was spent face-to-face with an established patient in the office and more than half of that time was spent counseling the patient or coordinating his or her care, CPT® code 99214 should be selected.

New Patient

E/M codes are divided into two categories, new or established patient for office visits. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.

CPT code and Allowed amount.

This is just an approximate allowed amount and for the exact amount , reach out to the insurance.

Established Patient

99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician . Usually the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.

Example: A patient returns to the office three days later to have PPD test evaluated and for instructions on self-administration of TNF-alpha inhibitor. The RN evaluates the PPD test and informs the rheumatologist that it is negative. The rheumatologist instructs RN to proceed with teaching patient self-administration of TNF-alpha inhibitor and provides RN with prescription for TNF-alpha inhibitor to give to patient. RN instructs patient on selfadministration of TNF-alpha inhibitor and patient is scheduled to return to office next week to give self TNF-alpha inhibitor injection under supervision of RN. The patient will return for routine E/M follow-up visit in one month.

The physician does not personally see patient during this visit, but is present in the office suite

99212 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components:

1. A problem-focused history • Chief complaint • Brief history of present illness 2. A problem-focused examination • A limited exam of affected body area or organ system 3. Straightforward medical decision making • Minimal number of diagnoses/management options • Minimal (or no) amount/complexity of data obtained, reviewed and analyzed • Minimal risk of complications/morbidity/mortality

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are self-limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

Example: This is a follow-up visit for a 35-year-old male seen before for pain and loss of motion in his right shoulder. He returns for follow-up after a course of medication, an intraarticular injection and physical therapy. Review of test results and a physical examination reveal that the patient is now better. The patient is told to return only if a new problem occurs. 99213 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components :

1. An expanded problem-focused history • Chief complaint • Brief history of present illness • Problem pertinent system review 2. An expanded problem-focused examination • A limited exam of affected body area or organ system and other symptomatic or related organ systems 3. Medical decision making of low complexity • Limited number of diagnoses/management options • Limited amount/complexity of data obtained, reviewed and analyzed • Low risk of complications/morbidity/mortality

Example: A 68-year-old woman comes in for a follow-up office visit; she has polymyalgia rheumatica maintained on chronic low-dose corticosteroids. The history reveals no increase in the shoulder or hip pain. There has been some mild weight gain and bruising while on the medication. A limited examination was performed. The patient was instructed on long-term prognosis of PMR and steroid side effects. Laboratory tests were ordered. 99214 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components:

1. A detailed history • Chief complaint • Extended history of present illness • Problem pertinent system review extended to include a review of a limited number of additional systems • Pertinent past, family, and/or social history directly related to the patient’s problems 2. A detailed examination • Extended exam of affected body area(s) and other symptomatic/related organ system(s) 3. Medical decision making of moderate complexity • Multiple number of diagnoses/management options • Moderate amount/complexity of data reviewed • Moderate risk of complications/morbidity/mortality

Counseling and/or coordination of care with other providers or agencies are provided, consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

99215 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components:

1. A comprehensive history • Chief complaint • Extended history of present illness • Review of systems which is directly related to the problem(s) identified in the history of present illness plus a review of all additional body systems. • Complete past, family, and/or social history

2. A comprehensive examination • A general multi-system exam or a complete exam of a single organ system

3. Medical decision making of high complexity • Extensive number of diagnoses/management options • Extensive amount/complexity of data obtained, reviewed and analyzed • High risk of complications/morbidity/mortality

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family

New & Established Office Visits

New Patient Office and Consultations:

• Must have documentation inall three categoriesof history, exam, and medical decision making to meet level of service OR

• May satisfy criteria by documentation of time when counseling and/or coordination of care is greater than 50% of the total time taken Definition of a “New Patient”

• CMS Definition:

“One who has not received a face-to-face evaluation and management service or procedure from a physician, or colleague of the same specialty (or subspecialty; AMA 2012) who belongs to the same group practice within the past 3 years. New patient status does not apply to admissions, critical care services or ER.”

• Based on Payor credentialing

• Mid-levels are non-designated (specialty) in most states Established Patients:

• Must have documentation inat least two categoriesof history, exam and medical decision making OR

• May satisfy criteria by documentation of time when counseling and/or coordination of care is greater than 50% of the total time taken

D. Use of Highest Levels of Evaluation and Management Codes Contractors must advise physicians that to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).

The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.

Summary of Criteria – Established Patient Established CPTCode (2 of 3 required) History Exam Decision

99211 (5 min) 1 HPI 1 body area or organ systems Straightforward

99212 (10 min) (1 stable condition or self limiting problem) 1 HPI 1 body area or organ systems Straightforward

99213 (15 min) (2 stable conditions or acute uncomplicated illness or injury) 2-3 HPI and 1 ROS 2-4 Body areas or organ systems Low

99214 (25 min) (worsening problem, undiagnosed new problem, or several existing problems) 4 or more elements or status of 3 chronic conditions; 2 to 9 ROS; and 1 PFSH 5-7 body areas or organ systems Moderate

99215 (40 min) (one or more chronic illness w/severe exacerbation, life threatening) 4 or more elements or status of 3 chronic conditions; 10 to 14 ROS; and 2 PFSH 8 or more organ systems High

Counseling and Coordination of Care

Clinical Example

Established Patient Times • 99211 = 5 • 99212 = 10 • 99213 = 15 • 99214 = 25 • 99215 = 40

Example of C & CC

• Patient returns for MRI results and discussion of treatment regarding her breast cancer. We discussed the role of chemotherapy and benefits of the current clinical trials. Patient understands side effects and consents to start treatment next week. Spent a total of 20 minutes with the patient, over half of which was counseling on treatment options.

• 99213 based on time.

Preoperative and Postoperative Billing Errors

Preoperative and postoperative billing errors occur when E&M services are billed with surgical procedures during their preoperative and postoperative periods. ClaimCheck bases the preoperative and postoperative periods on designations in the CMS National Physician Fee Schedule. For example, if a provider submits procedure code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making [10 minutes]) with a DOS of 11/02/08 and procedure 27750 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation) with a DOS of 11/03/08, ClaimCheck will deny procedure code 99212 as a preoperative visit because it is submitted with a DOS one day prior to the DOS for procedure code 27750. Services Provided by Ancillary Providers

Claims for services provided through telemedicine by ancillary providers should continue to be submitted under the supervising physician’s NPI (National Provider Identifier) using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician and documented in the same manner as face-to-face services. Coverage is limited to procedure codes 99211 or 99212, as appropriate.

Primary Care Treatment and Follow-up Care for Mental Health and Substance Abuse

Initial primary care treatment and follow-up care are covered for members with mental health and/or substance abuse needs provided by primary care physicians, physician assistants, and nurse practitioners. Wisconsin Medicaid will reimburse the previously listed providers for CPT (Current Procedural Terminology) E&M (evaluation and management) services (procedure codes 99201-99205 and 99211-99215) with an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code applicable for mental health and/or substance abuse services. As a reminder, these services may be eligible for HPSAs (Health Professional Shortage Areas) and pediatric enhanced reimbursements. Refer to the latest edition of CPT or to the CMS (Centers for Medicare and Medicaid Services) 1995 or 1997 Documentation Guidelines for Evaluation and Management Services via the CMS Web site for guidelines for determining the appropriate level of E&M services.

Since counseling may constitute a significant portion of the E&M services delivered to a member with mental health and/or substance abuse diagnoses, providers are required to fully document the percentage of the E&M time that involved counseling. This documentation is necessary to justify the level of E&M visit. Claims for services delivered by ancillary staff under the direct, on-site supervision of a primary care physician must be submitted under the NPI (National Provider Identifier) of the supervising physician. Coverage and reimbursement are limited to CPT code 99211 or 99212 as appropriate. Tobacco Cessation Drugs and Services

Tobacco cessation services are reimbursed as part of an E&M (evaluation and management) office visit provided by a physician, physician assistant, nurse practitioner, and ancillary staff. Services must be one-on-one, face-to-face between the provider and the member. BadgerCare Plus does not cover group sessions or telephone conversations between the provider and member under the E&M procedure codes. Tobacco cessation services covered under BadgerCare Plus and Wisconsin Medicaid include outpatient substance abuse services or outpatient mental health services, as appropriate. Tobacco cessation services covered under the BadgerCare Plus Core Plan include medically necessary E&M visits, as appropriate.

Ancillary staff can provide tobacco cessation services only when under the direct, on-site supervision of a Medicaid-enrolled physician. When ancillary staff provide tobacco cessation services, BadgerCare Plus reimburses up to a level-two office visit (CPT (Current Procedural Terminology) code 99212). The supervising provider is required to be listed as the rendering provider on the claim.

Health Professional Shortage Area-Eligible Procedure Codes Providers may submit claims with HPSA modifier “AQ” (Physician providing a service in a HPSA). While the modifier is defined for physicians only, any Medicaid HPSA-eligible provider may use them with the following procedure codes

Bundling Guidelines of Consult code to 99211 – 99215 – bcbs insurance

BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212 99242 to 99212 99243 to 99213 99244 to 99214 99245 to 99215

Office Visits – Office services provided on an emergency basis (99058) are considered mutually exclusive to the primary services provided.

Office visit (99211) is considered mutually exclusive to 95115-95117(allergen immunotherapy). Separate reimbursement is not allowed for mutually exclusive services. Pap Smears – Obtaining a pap smear is integral to the office visit. This includes both preventive and routine office visits. Separate reimbursement is not allowed for Q0091.

Pathologists – Claims submitted by pathologists (provider specialty 29) for clinical interpretation of laboratory results will be allowed for codes 83020, 84165, 84166, 84181, 84182, 85060, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, and 87207. Pathology interpretation of all other codes in the 80002-87999 range is considered integral to the laboratory test. Separate reimbursement is not allowed for integral services.

Pulse Oximetry – Pulse oximeters are considered incidental to office visits or procedures. Separate reimbursement is not provided for incidental procedures.

Respiratory Treatments – Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB devise is considered mutually exclusive to an office visit. Separate reimbursement is not provided for mutually exclusive services.

Robotic Surgical Systems – Payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.

STAT or After Hours Laboratory Charges – Additional charges for STAT or after hours laboratory services are considered an integral part of the laboratory charge.

Surgical Supplies – Surgical supplies will be considered incidental to Surgical; Laboratory; Inpatient, Outpatient or Office Medical Evaluation and Management; and Consultation services. Surgical dressings applied in the provider’s office are considered incidental to the professional services of the health care practitioner and are not separately payable. Surgical dressings billed in the provider’s office (place of service 11) will be denied.

Surgical trays and miscellaneous medical and/or surgical supplies are generally considered incidental to all medical, chemotherapy, surgery, and radiology services, including those performed in the office setting.

Supplies (except those related to splinting and casting) are considered components of the 0, 10, and 90- day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure.

Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit.

Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.

Transvaginal Ultrasound – Transvaginal ultrasound (76830) is considered mutually exclusive to a hysterosonography with or without color flow Doppler (76831). Venipuncture – Refer to policy “Code Bundling Rules Not Addressed in Claim Check.”

Vision Services – Determination of refractive state (92015) performed incidental to a medical eye exam is permissible and may be covered when performed outside of any global allowance and subject to member benefits.

X-Rays – When single view and double view chest X-Rays are billed together (71010 and 71020), only the double view X-Ray is allowed. When the entire spine, survey study is billed (72082) with cervical spine films (72040), thoracic spine films (72070) or lumbosacral spine films (72100) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view XRay code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowable per X-Ray.

Examples of billable and non-billable prolonged services follow with CPT 99213 and 99212

Billable Prolonged Services

A physician performed a visit that met the definition of an office visit CPT code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills CPT code 99213 and one unit of code 99354.

EXAMPLE 2 A physician performed a visit that met the definition of a domiciliary, rest home care visit CPT code 99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills CPT codes 99327, 99354, and one unit of code 99355.

A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician bills CPT code 99215 and one unit of code 99354. ?

Non-billable Prolonged Services

A physician performed a visit that met the definition of visit code 99212 and the total duration of the direct face-to-face contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct face-toface service did not meet the threshold time for billing prolonged services.

A physician performed a visit that met the definition of code 99213 and, while the patient was in the office receiving treatment for 4 hours, the total duration of the direct face-to-face service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.

A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

Finally, you should remember that Medicare contractors will not pay (nor can you bill the patient) for prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls). These are Medicare covered services and payment is included in the payment for other billable services.

Medical billing code 99213

This Medical billing code 99213 address audits the method code definition, advancement note illustrations, RVU values, national dispersion information and clarifies when this code ought to be utilized as a part of the healing center setting. CPT remains for Current Procedural Terminology. This code is a piece of a group of therapeutic charging codes depicted by the numbers Medical billing code 99213 speaks to the center (level 3) office or other outpatient set up office patient visit and is a piece of the Healthcare Common Procedure Coding System (HCPCS). This technique code address for built up office patient visits is a piece of a complete arrangement of CPT® addresses composed without anyone else. I am a board affirmed inner solution doctor with more than ten years of clinical hospitalist involvement in a group hospitalist project giving doctor administrations to a vast local healing center framework. I have composed my accumulation of assessment and administration (E/M) addresses throughout the years to help doctors and other non-doctor professionals (medical caretaker experts, clinical attendant masters, confirmed medical caretaker birthing specialists and doctor partners) comprehend the unpredictable and obsolete universe of healing facility and center based coding prerequisites.

These unique addresses and going with assets are utilized independent from anyone else to stay consistent with the guidelines and regulations of the Centers for Medicare and Medicaid Services (CMS). All my CPT® addresses (counting Medical billing code 99213 and CPT® 99215) have been composed in one simple to-discover asset on Pinterest and can be gotten to by clicking this connection. You don’t should be a Pinterest part to access any of my CPT® method addresses. As you ace these CPT® E/M technique codes, recall that, you have a commitment to ensure your documentation underpins the level of administration you are submitting for installment. The volume of your documentation ought not be utilized to decide your level of administration. The subtle elements of your documentation are what matter most. Moreover, the E/M administrations aide says the consideration you give must be “sensible and vital” and all passages ought to be dated and contain a CMS characterized neat mark or mark confirmation, if important.

99213 MEDICAL CODE DESCRIPTION

Office or other outpatient visit for the assessment and administration of a built up patient, which requires no less than two of these three segments: An extended issue centered history; An extended issue centered examination; Medical choice making of low unpredictability. Directing and coordination of consideration with different suppliers or organizations are given predictable the way of the problem(s) and the understanding’s and/or family’s necessities. For the most part, the exhibiting problem(s) are of low to direct seriousness. Doctors ordinarily burn through 15 minutes up close and personal with the patient and/or crew.

A built up patient is characterized as a person who has gotten proficient administrations from a specialist or another specialist of precisely the same and subspecialty who fit in with the same gathering practice inside of the previous three years.

This medicinal charging code can be charged in light of time when certain necessities are met. Documentation of time is not required to stay consistent with CMS regulations. In the event that charged without time as a thought, CPT® 99213 documentation ought to be bolstered by the 1995 or 1997 E/M rules referenced previously. The three critical coding parts for a built up outpatient center note are the:

Physical Exam

Medicinal Decision Making Complexity

For all settled office patient charging codes (99211-99215), the most noteworthy recorded two out of three above parts decides the right level of administration code. Contrast this and the prerequisite for the most elevated reported three out of three above parts for new office patient consideration experiences (99201-99205). Once more, just the most elevated two out of three parts are expected to decide the right level of tend to CPT® 99213. The accompanying examination points of interest the base prerequisites important to stay agreeable with CPT® 99213. Furthermore, as with all E/M experiences, an eye to eye experience is constantly required. Then again, on account of outpatient center codes, Medicare allows episode to charging, where the administration is given by somebody other than the doctor. On the off chance that sure prerequisites are met, the doctor may gather 100% of passable charges in these circumstances. Administrations charged occurrence to are charged under the doctor’s supplier number.Medical billing code 99213 Extended issue centered history: Requires just 1-3 parts for the historical backdrop of present sickness (HPI) OR documentation of the status of THREE unending restorative conditions. No past restorative history or social history or family history is required. Just 1 issue apropos audit of frameworks (ROS), that asks about the framework identified with the issue recognized in the HPI, is required.

Extended issue centered examination: 1997 rules require documentation of no less than six components recognized by a slug in one or more organ systems(s) or body area(s). 1995 rules require a restricted examination of the influenced body region or organ framework and other symptomatic or related organ system(s). The CMS E&M guide on pages 31 and 32 portrays the adequate body ranges and organ frameworks on physical exam.

Therapeutic choice making of low intricacy (MDM): This is split into three parts. The 2 out of 3 most elevated amounts in MDM are utilized to decide the general level of MDM. The level is dictated by a perplexing arrangement of focuses and hazard. What are the three parts of MDM and what are the base required number of focuses and hazard level as characterized by the Marshfield Clinic review instrument?

Finding (2 focuses)

Information (2 focuses)

Danger (low);

The restorative choice making point framework is exceedingly mind boggling. I have a point by point reference to it on my E/M pocket cards depicted underneath. These cards offer me some assistance with understanding what kind of consideration my documentation underpins. I convey these trick sheet cards with me at all times and reference every one of them day long. As a hospitalist who performs E/M benefits solely, these cards have kept me from under and over charging a huge number of times throughout the most recent decade.

CLINICAL EXAMPLES OF 99213

What are some advancement note documentation illustrations for a CPT® 99213, the level 3 built up patient visit in an office or other outpatient setting? Most specialists utilize the subject, goal, appraisal and arrangement (SOAP) note group. A 99213 note could resemble this:

S) No more stomach torment (1 HPI). Gentle Nausea (1 issue relevant ROS)

O) 120/80 Tmax 98.9 (three fundamental signs = one slug) guts no masses; lungs clear; heart no mumble; legs no edema; skin no impulsive. (no less than 6 downright shots)

A) Nothing required

P) Nothing required

In this sample history (subjective) and physical (goal) meet the prerequisites to get paid for a 99213. Keep in mind, the most elevated 2 out of 3 segments decide the largest amount of administration for set up patients in the center or other outpatient setting. Do note that connecting an ICD code to a CPT® restorative code is required for all visits submitted to CMS for repayment. Accordingly, most advance notes ought to give no less than one ICD code to unmistakably show a reason for the visit. I think this is important to meet the sensible and vital edge, unless that can be derived from other diagram documentation. Medicare wouldn’t like to pay for specialists to discuss legislative issues with their patients. There must dependably be an endorsed ICD code connected with the CPT® restorative code when charged to CMS and most other insurance agencies.Medical billing code 99213

Here is another clinical case of a SOAP note for a CPT® 99213 set up patient facility visit:

S)No SOB (1 issue appropriate ROS)

O) 120/80 Tmax 98.9 (three basic signs = one projectile) guts no masses; lungs clear; heart no mumble; legs no edema; skin no impulsive. (no less than 6 all out shots)

A)HTN-stable, no progressions arranged.

DM-stable, no progressions arranged.

COPD-stable, no progressions arranged. (the status of three endless medicinal conditions set up of HPI)

As you probably are aware, reporting the status of three incessant restorative conditions can substitute for the HPI. Include one issue correlated audit of framework and this is the base history

The going to doctor ought to look over the perception gathering of therapeutic codes 99218-99220 for the introductory experience, 99224-99226 for perception status subsequent codes, and 99217 for perception release. Under specific circumstances, same day concede and release charging codes 99234-99236 or basic consideration method

Medical code 99214 , if charged effectively, can build income for the practice. By just utilizing CPT code 99212 and CPT code 99213 numerous suppliers are losing a huge number of dollars in true blue income yearly. Which can be maintained a strategic distance from with the right charging of the 99214 E/M Code.

The CPT meaning of another patient experienced unpretentious changes in 2012. Sadly, CMS did not change their definition to stay adjusted to these progressions. This distinction in dialect has brought on awesome disarray for some qualified human services specialists attempting to stay agreeable with the mind boggling standards and regulations of E&M.

Another patient is one who has not got any expert administrations from the doctor/qualified social insurance proficient or another doctor/qualified medicinal services proficient of precisely the same and subspecialty who fits in with the same gathering practice, inside of the previous three years.

CPT Code 99214,99213 E/M Coding Established Office Patient Correctly for Medicare Reimbursement

Medical code 99214 is allocated to the therapeutic administration that agrees to the accompanying necessities:

The patient is a set up one, which means is not their first visit.

It must be an outpatient visit, which means it must not consolidate a day of clinic time.

It must meet or surpass to of the accompanying three focuses:

A point by point therapeutic history

A point by point therapeutic exam

A therapeutic choice that involves moderate multifaceted nature.

The seriousness of the issue that conveys the patient to the center must be from a moderate to a high one. 5. What’s more, last, the specialist and the patient ought to have a greatest of 25 minutes acknowledgment.

Medical code 99214

CPT code 99214 Increases Medicare Revenue

Medicare and other Insurance are satisfied to pay the lesser cash to suppliers on the off chance that they (the specialists) are willing to under utilize the CPT code 99214. The way to utilizing this code accurately is to comprehend the best possible use and the parts required to completely catch the most out of the majority of your experiences. As a supplier, you will be compensated the your rewards for all the hard work when you set aside an ideal opportunity to take in the parts of this code and utilize it appropriately.

When you consider CPT code 99214 it has a higher return rate connected to it, be that as it may, it must fall under the domain of a moderate unpredictability to a high seriousness issue. The doctor, if utilizing time as a variable more likely than not spent no less than 25 minutes in an eye to eye situation with the patient. In any case, the time part is just an aide and not totally required if the segments are incorporated into the visit and the required therapeutic need is available. The doctor must have the capacity to outfit the a few ranges which incorporate history, physical exam and therapeutic choice making with the best possible documentation when petitioning for the CPT code 99214.

The patient experience, made out of an itemized history, nitty gritty patient exam and moderate many-sided quality in the restorative choice making will legitimize the utilization of CPT code 99214 the length of the medicinal need is evident.

For instance, you have a set up office tolerant with hypertension, diabetes and a background marked by dyslipidemia who you are seeing on follow up in the workplace. Under the 1997 rules you can utilize three constant and stable conditions to fit the bill for the higher code inside of the history segment.

Archive the drugs and the survey of frameworks alongside the best possible past medicinal, family and social history and the first segment is met. Record the best possible physical exam utilizing proper organ framework approach six regions with two slugs each and you have met the necessity for the many-sided quality on this region.

As of right now, actually you have come to the level 4 criteria since there just should be two out of three parts required for a built up patient.

On the other hand, we feel that it is hard to not have a restorative choice making segment so we incorporate that into our advancement note. You can record the lab results for the patient and further set the visit to qualify at the higher code. For whatever length of time that the restorative need is available to legitimize the work done amid the visit the coding can be at the larger amount.

99214 versus 99213 CPT Codes Billing

In above Example, most suppliers will code the illustration as a CPT 99213, on the other hand, the qualifiers are available for the higher 99214 code.

While assessing three distinctive medicinal issues, for example, Hypertension, Diabetes and Hyperlipidemia, utilizing the 1997 standards, you have met the restorative need segment also, because of the need to screen these illnesses and help the patient with his/her control.

Be that as it may, meeting the correct criteria required to code the experience will empower a restorative biller to get the prizes for the his vocation and his practice. It additionally get to be vital, becaue now days Medical Billing and Coding Business are confronting potential cuts in the repayments for the administrations the bill.

Get Medicare billing update instantly

Medicare reimbursement articles.

Sample appeal letter – Medically not necessary denial
RCM Business Full checklist for all process
CPT Codes 0185U, 0186U, 0187U -Genotyping (Fut1), Gene Analysis,
CPT Codes 0197U, 0198U, 0199U – Red Cell Antigen
CPT code 0055U, 0056U, and 0058U – Cardiology (Heart Transplant
CPT Code 0005U, 0006M, 0007M – Oncology Real Time PCR
Procedure code 97597, 97598 – updated Billing Guide
Home health services – CPT code list
BCBS prefix – Why its important to read correctly.
MCO – MIS and reporting system

Medicare Guidelines visitors

Medicare payment basics

Evaluation and management (E/M) services are an essential part of medical practices, especially in family medicine. These services are categorized using Current Procedural Terminology (CPT) codes for billing purposes. Properly documenting and coding for E/M services is crucial to maximize payment and minimize audit-related stress.

There are different levels of E/M codes, determined by the medical decision-making or time involved. It’s worth noting that the guidelines for E/M coding have undergone changes, including the elimination of history and physical exam elements, revisions to the MDM table, and an expanded definition of time for E/M services.

Key Takeaways:

Understanding E/M codes and guidelines is crucial for accurate billing.
There are different levels of E/M codes based on medical decision-making or time involved.
Recent changes to E/M coding include the elimination of history and physical exam elements.
The definition of time for E/M services has been expanded.
Proper documentation and coding help maximize payment and reduce audit-related stress.

Overview of Office Visit CPT Code Changes

The CPT Editorial Panel made significant revisions to the documentation and coding guidelines for office visit E/M services in 2021, with further changes introduced in 2023. These updates aim to simplify documentation requirements, reduce administrative burden, and ensure accurate coding for evaluation and management services.

One of the key changes introduced is the addition of add-on code G2211. This code accounts for the resource costs associated with visit complexity inherent to primary care and other longitudinal care settings. The inclusion of this add-on code reflects a more comprehensive understanding of the unique challenges and workload associated with these types of visits.

Additionally, the revisions eliminate the requirement for history and physical exam elements to be considered in E/M code level selection. This change allows healthcare providers to focus more on medical decision-making (MDM) and limits the need for extensive documentation of these elements in the medical record.

The MDM table has also been revised to better reflect the cognitive work required for evaluation and management services. This ensures that the complexity of the MDM is accurately captured in the coding process and supports appropriate reimbursement for the level of care provided.

Furthermore, the definition of time for many E/M services has been expanded. The expanded definition of time includes both face-to-face and non-face-to-face components of care on the day of the encounter. This change recognizes the comprehensive nature of care provided and allows for a more accurate reflection of the time spent in the management of the patient.

Using Total Time for Office Visit CPT Code Selection

When it comes to selecting the appropriate office visit CPT code, total time can be a valuable factor to consider. Total time refers to the sum of all the physician’s or qualified health professional’s (QHP) time spent in caring for the patient, both face-to-face and non-face-to-face, on the day of the encounter. This expanded definition of time allows for a more comprehensive evaluation and management of the patient’s needs.

Total time can be utilized in selecting the level of service for various evaluation and management services, including office visits, inpatient and observation care, consultations, nursing facility services, home and residence services, and prolonged services. It provides a broader perspective on the physician’s involvement in the patient’s care, taking into account all aspects of their interaction.

However, it’s important to note that for emergency department visits, the level of service is still determined primarily by medical decision-making (MDM), rather than total time. This distinction recognizes the critical nature of emergency care and the need for prompt assessment and action.

Accurate documentation of the total time spent is key to ensuring proper code selection and appropriate reimbursement. The total time should be well-documented in the patient’s medical record, including both the face-to-face and non-face-to-face components of the encounter. This documentation serves as a crucial reference point for billing and auditing purposes.

To summarize, total time offers a comprehensive perspective on the physician’s engagement with the patient, encompassing both face-to-face and non-face-to-face interactions. It allows for a more accurate selection of office visit CPT codes and ensures the appropriate level of reimbursement for the provided services. Proper documentation of total time is essential to support the medical necessity of the encounter and maintain compliance with coding and billing guidelines.

Documentation Requirements for Total Time Calculation

When determining the total time for selecting office visit CPT codes, it is essential to adhere to specific documentation requirements. By accurately documenting the time spent on various activities during the encounter, healthcare providers can ensure proper code selection and optimize reimbursement.

To calculate the total time for office visit code selection, the following activities should be included:

Reviewing external notes/tests
Performing an examination
Counseling and educating the patient
Documenting in the medical record

These activities reflect the time personally spent by the physician or qualified health professional (QHP) on the date of the encounter. However, there are also activities that should be excluded when calculating total time:

Time spent on activities typically performed by ancillary staff
Time related to separately reportable activities

It is crucial to specifically document the total time spent on each activity during the date of the encounter, rather than providing generic time ranges. This detailed documentation ensures transparency and accuracy in code selection and reimbursement.

In addition to capturing face-to-face time, it is important to record non-face-to-face time as well. Non-face-to-face time includes tasks performed outside of direct interaction with the patient, such as reviewing test results or consulting with other healthcare professionals.

Example of Total Time Calculation:

Let’s consider an example where a family physician spends the following time on a patient encounter:

45 minutes performing an examination and counseling
15 minutes reviewing external notes/tests
10 minutes documenting in the medical record
5 minutes discussing with an ancillary staff

In this case, the total time would be calculated as follows:

By accurately documenting the specific total time spent on each activity and excluding ancillary staff time, healthcare providers can ensure proper code selection and reimbursement. This meticulous documentation of total time in the medical record provides a comprehensive overview of the services rendered and supports accurate billing.

Split or Shared Visit Documentation Guidelines

A split or shared visit occurs when a physician and other qualified health professional (QHP) provide care to a patient together during a single Evaluation and Management (E/M) service. In such cases, the time personally spent by the physician and QHP on the date of the encounter should be summed to define the total time.

However, only distinct time should be counted. This means that overlapping time during jointly meeting with or discussing the patient should not be double-counted. The distinct time should represent the unique contribution of each provider involved in the split or shared visit.

It is important to note that time spent on activities performed by ancillary staff should not be included in the total time calculations. The total time should only reflect the face-to-face time and distinct time spent by the physician and other QHP directly involved in providing the medically necessary services.

Documentation should support the medical necessity of both services reported in a split or shared visit scenario. This includes clearly documenting the need for both physicians or QHPs to be involved and the services each provider contributed to the patient’s care.

Applying Total Time to Specific E/M Services

Total time is a valuable tool for selecting the appropriate level of service for a variety of Evaluation and Management (E/M) services. This method can be applied to different specific E/M services, ensuring that the level of care is clinically appropriate and adequately reimbursed. By considering the total time spent during the encounter, healthcare providers can accurately assign the appropriate office visit CPT code.

The application of total time is not limited to office visit services. It can also be used for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services. This flexibility allows for a comprehensive approach to E/M coding, regardless of the specific type of service provided.

When selecting the visit level based on total time, it is important to ensure that the encounter is counseling-dominated. While total time can be used as the sole determinant for selecting the visit level, counseling should still play a significant role in the encounter. This ensures that the level of service reflects the complexity and intensity of the counseling provided during the visit.

It is crucial to emphasize that total time should be clinically appropriate and supported by documentation in the medical record. This documentation should clearly demonstrate the medical necessity of the services provided and the time spent on the date of the encounter.

Applying Total Time to E/M Services: An Example

To illustrate the application of total time to specific E/M services, let’s consider an example of an office visit for a counseling-dominated encounter:

In this example, the total time spent during the encounter determines the appropriate level of visit code. For a total time of 25 minutes, a level 3 visit (CPT code 99213) is selected. If the total time is 40 minutes, a level 4 visit (CPT code 99214) would be appropriate. Finally, a total time of 60 minutes would result in a level 5 visit (CPT code 99215).

By applying total time to specific E/M services, healthcare providers can ensure accurate coding and appropriate reimbursement for the care provided. This method promotes comprehensive and patient-centered care while maintaining compliance with coding guidelines. Understanding the nuances of applying total time is essential for optimizing billing practices and promoting quality healthcare delivery.

Caveats and Considerations for Time-based E/M Coding

When utilizing time as the basis for selecting E/M codes, there are important caveats and considerations to keep in mind. Time-based coding should only be used in situations where counseling dominates the encounter, and it should not include time spent on separately reportable services. Documentation should clearly indicate that the services provided were not duplicative and were necessary for the management of the patient. Additionally, it is crucial to note that the professional component of diagnostic tests/studies and activities performed on a separate date should not be included in the total time calculation.

Considerations for Time-based E/M Coding

Use time-based coding only when counseling dominates the encounter.
Exclude time spent on separately reportable services.
Ensure documentation supports the necessity of the provided services.
Do not include the professional component of diagnostic tests/studies.

Implications of Time-based E/M Coding

When selecting E/M codes based on time, it is important to adhere to the specified guidelines and considerations. Failing to do so can lead to inaccurate coding, reimbursement issues, and potential compliance concerns. By understanding the requirements and accurately documenting the relevant information, healthcare providers can ensure proper medical billing and maintain compliance with coding and documentation guidelines.

Documentation Requirements for Time-based E/M Coding

Updates and Changes to CPT E/M Guidelines

The CPT Editorial Panel has recently implemented updates and changes to the Evaluation and Management (E/M) guidelines, specifically focusing on medical decision making (MDM), history, and exam. These updates aim to enhance the accuracy and specificity of E/M coding and documentation.

One significant change in the new guidelines is the emphasis on a medically appropriate history or exam, rather than relying solely on the number or complexity of problems addressed. This shift highlights the importance of gathering comprehensive patient information to guide medical decision making.

The MDM levels have also been revised to align with those used for office visits. This alignment ensures consistency across different types of E/M services and facilitates accurate code selection for medical billing and reimbursement.

By updating and refining the guidelines, the CPT Editorial Panel aims to streamline the coding and documentation process, making it easier for healthcare providers to accurately capture the complexity of patient encounters and facilitate proper reimbursement.

Changes in CPT E/M Guidelines

The updates in the CPT E/M guidelines bring about significant changes in capturing the complexity of patient encounters. Healthcare providers should familiarize themselves with these updates to ensure compliance with the revised guidelines, thereby facilitating accurate coding, billing, and reimbursement.

Guidelines for MDM Selection in E/M Services

In the process of selecting the appropriate E/M codes for evaluation and management (E/M) services, medical decision making (MDM) plays a crucial role. MDM encompasses several factors that need to be considered, including the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

It is important to note that the final diagnosis alone does not determine the complexity of MDM. Rather, the complexity is determined by the impact of the condition on the management of the patient. The more complex the problems, comorbidities, and data analysis, as well as the higher the risk of complications, morbidity, or mortality, the more intricate the MDM.

In accurately reflecting the level of complexity in the documentation and coding of E/M services, healthcare providers ensure proper reimbursement and compliance with coding guidelines. By carefully evaluating the factors that contribute to MDM, providers can effectively demonstrate the complexity of the problems addressed and the resources required to manage them.

Here is a breakdown of the key considerations for MDM selection in E/M services:

Number and complexity of problems addressed
Comorbidities
Amount and complexity of data reviewed and analyzed
Risk of complications, morbidity, or mortality
Final diagnosis and its impact on management
Complexity of problems and their management

Accurately documenting and coding the appropriate level of MDM is essential for ensuring proper reimbursement and comprehensive representation of the complexity of the patient’s condition. It is crucial to pay attention to the specifics of each patient’s case and make informed decisions based on thorough evaluation and analysis.

Impact of Office Visit CPT Code Changes on Medical Billing

The changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. Healthcare providers must adapt to these changes and understand the documentation requirements and accurate coding necessary to ensure proper reimbursement and reduce the risk of audits.

Accurate coding is crucial in accurately reflecting the level of service provided during the office visit. It ensures that healthcare providers receive accurate reimbursement for their services and helps to reduce the burden of potential audits. Proper documentation and coding also contribute to compliance with coding and documentation requirements, mitigating the risk of financial loss and noncompliance.

It is essential for healthcare providers to familiarize themselves with the new guidelines and understand how to properly document the relevant information. This includes accurately capturing the level of service provided, the complexity of problems addressed, and the time spent on the date of the encounter. By adhering to these documentation requirements, healthcare providers can ensure accurate coding and reimbursement, reducing the risk of claims denials or audits.

Proper documentation not only helps in accurate coding and reimbursement but also simplifies auditing processes, ensuring compliance with coding and documentation requirements. Auditing plays a vital role in the healthcare system, and having the appropriate documentation in place can streamline the auditing process and provide evidence of accurate and compliant billing practices.

Compliance with coding and documentation requirements is essential to avoid potential financial loss and maintain a good standing within the healthcare industry. By accurately documenting and coding office visit services, healthcare providers can demonstrate their commitment to compliance and ensure that they are providing high-quality care to their patients.

In conclusion, the changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. It is crucial for healthcare providers to understand the documentation requirements, accurately code the services provided, and ensure compliance with coding and documentation guidelines. By doing so, healthcare providers can streamline the billing process, reduce the risk of audits, and ensure accurate reimbursement for their services.

Resources for Understanding Office Visit CPT Code Guidelines

When it comes to understanding the guidelines for office visit CPT codes and navigating the changes in E/M coding, healthcare providers can rely on valuable resources provided by reputable organizations such as the American Medical Association (AMA) and the Medicare Learning Network (MLN). These resources offer comprehensive guidance and tools that can help healthcare providers stay up to date and ensure accurate reimbursement.

The CPT Evaluation and Management Services Guidelines, developed by the AMA, provide detailed information on office visit CPT codes, E/M coding principles, and documentation requirements. This resource serves as a comprehensive guide to help healthcare providers understand the intricacies of office visit coding and ensure compliance with the latest guidelines.

The Medicare Learning Network, an educational resource developed by the Centers for Medicare & Medicaid Services (CMS), offers webinars, articles, and other educational materials specifically designed to assist healthcare providers in understanding and implementing the changes in E/M coding. These resources provide practical insights and clarification on the documentation requirements and coding changes specific to office visit CPT codes.

Furthermore, the Medicare Physician Fee Schedule Lookup Tool, available on the CMS website, enables healthcare providers to access reimbursement information for specific office visit CPT codes. This tool allows providers to accurately determine the appropriate reimbursement for their services and ensure proper billing practices.

By leveraging these resources, healthcare providers can enhance their understanding of office visit CPT code guidelines, navigate the complexities of E/M coding, and ensure accurate reimbursement for their services. Staying informed and utilizing these valuable resources is imperative for maintaining compliance and optimizing coding practices.

Understanding the guidelines for office visit CPT codes is essential for accurate medical billing and insurance reimbursement. The recent changes in E/M coding guidelines, particularly regarding time-based code selection and medical decision making, necessitate proper documentation and accurate coding. By comprehensively understanding these guidelines, healthcare providers can maximize their payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

Accurate medical billing is crucial for healthcare practices to receive fair reimbursement from insurance companies. By following the comprehensive guide provided by the American Medical Association (AMA) and the Medicare Learning Network (MLN), healthcare providers can confidently navigate the complexities of office visit CPT codes. This comprehensive guide provides detailed information on selecting the appropriate codes based on medical decision making, time-based code selection, and documentation requirements.

Properly documenting the relevant information and coding accurately not only ensures accurate reimbursement but also reduces the risk of audits and increases compliance. By adhering to the guidelines and best practices outlined in the comprehensive guide, healthcare providers can maintain accurate and compliant medical billing practices, ultimately benefiting both their practice and their patients.

In conclusion, understanding the guidelines for office visit CPT codes is crucial for accurate medical billing and insurance reimbursement. By following the comprehensive guide provided by industry resources such as the AMA and MLN, healthcare providers can navigate the changes in E/M coding and ensure compliance with coding and documentation requirements. This comprehensive understanding of the guidelines allows healthcare providers to optimize payment, minimize audit-related stress, and maintain accurate and compliant medical billing practices.

What are office visit CPT codes?

Office visit CPT codes are evaluation and management (E/M) codes used for billing purposes in family medicine practices and other healthcare settings.

What are the changes to the office visit CPT code guidelines?

The office visit CPT code guidelines have been revised to eliminate the history and physical exam elements, introduce an add-on code for visit complexity, revise the medical decision-making table, and expand the definition of time for E/M services.

How can total time be used for office visit CPT code selection?

Total time, which includes both face-to-face and non-face-to-face interactions, can be used to select the level of service for office visit codes and other E/M services.

What should be included in the calculation of total time for office visit code selection?

Activities such as examining the patient, counseling and educating the patient, reviewing external notes/tests, and documenting in the medical record should be included in the calculation of total time. Ancillary staff time and time related to separately reportable activities should be excluded.

How should total time be documented for office visit code selection?

It is important to document the specific total time spent on activities on the date of the encounter in the patient’s medical record, rather than providing generic time ranges.

What are the documentation guidelines for split or shared visits?

In a split or shared visit scenario, the time personally spent by the physician and other qualified health professional (QHP) should be summed to define total time. Distinct time should be counted, and time spent on activities performed by ancillary staff should not be included.

Can total time be used for other E/M services besides office visits?

Yes, total time can be used to select the level of service for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services.

What are the caveats and considerations for time-based E/M coding?

Time-based coding should only be used when counseling dominates the encounter, and it should not include time spent on separately reportable services. It is important to ensure that the services provided were necessary for the management of the patient.

What updates have been made to the CPT E/M guidelines?

The CPT E/M guidelines have been updated to emphasize the need for a medically appropriate history or exam and to revise the levels of medical decision making to align with office visit levels.

How is medical decision making (MDM) determined in E/M services?

MDM is determined by considering the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

What is the impact of the office visit CPT code changes on medical billing?

The changes in office visit CPT code guidelines have a significant impact on medical billing, requiring proper documentation and accurate coding to ensure accurate reimbursement and reduce the risk of audits.

Where can healthcare providers find resources to understand the office visit CPT code guidelines?

Healthcare providers can refer to resources such as the CPT Evaluation and Management Services Guidelines from the American Medical Association and the Medicare Learning Network for guidance on understanding and implementing the office visit CPT code guidelines.

What is the importance of understanding office visit CPT code guidelines?

Understanding office visit CPT code guidelines is crucial for accurate medical billing, insurance reimbursement, and compliance with coding and documentation requirements.

What is the overall purpose of the comprehensive guide on office visit CPT code guidelines?

The comprehensive guide on office visit CPT code guidelines provides healthcare providers with a thorough understanding of the guidelines, enabling them to maximize payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

AVAILABLE MON-FRI

From 8 am to 8 pm mst, houston office:.

525 N Sam Houston Pkwy E, Suite #246 Houston, Texas, 77060

Denver Office:

3000 Lawrence Street Suite #15 Denver, CO 80205

Tampa Office:

260 1st Ave S, #34 St Petersburg, Florida 33701

Phoenix Office:

7042 E Indian School Rd #100 Scottsdale, AZ 85251

Digital Marketing by Denver Digital Marketing Agency

List With CPT Codes For New Patient Office Visits | Short & Long Descriptions and Lay-Terms

4 CPT codes describe the procedures for a new patient office visit . These codes are used to record the level of complexity of the evaluation, management, and medical decision-making during the visit. You can find a complete list of office visits for both established patients and new patients here.

1. CPT Code 99202

Lay-term: CPT code 99202 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and straightforward medical decision making. The total time spent on the encounter must be 15 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.

Short description: New patient office visit, straightforward medical decision making, 15 minutes.

1.2. CPT Code 99203

Lay-term: CPT code 99203 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a low level of medical decision making. The total time spent on the encounter must be 30 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.

Short description: New patient office visit, low level medical decision making, 30 minutes.

1.3. CPT Code 99204

Lay-term: CPT code 99204 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a moderate level of medical decision making. The total time spent on the encounter must be 45 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.

Short description: New patient office visit, moderate level medical decision making, 45 minutes.

1.4. CPT Code 99205

Lay-term: CPT code 99205 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a high level of medical decision making. The total time spent on the encounter must be 60 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.

Short description: New patient office visit, high level medical decision making, 60 minutes.

How To Use CPT Code 28153

CPT 28153 describes the surgical procedure of resection of the condyle at the distal end of the phalanx, resulting in the amputation of the toe. This article will provide an overview of CPT code 28153, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples….

Medicare Releases Guidelines For Model 4 Bundled Payments

The Centers for Medicare & Medicaid Services (CMS) is conducting a pilot program to test bundling payment for services that patients receive during a single episode of care, such as heart bypass surgery or a hip replacement. The Bundled Payments for Care Improvement (BPCI) program seeks to encourage doctors, hospitals, and other health care providers…

Medicare payment allowances for flu vaccines

The Medicare Part B payment allowances for dates of service of August 1, 2018, through July 31, 2019 is furnished below. The allowances are still pending for the following codes CPT 90630, CPT 90653, CPT 90654, CPT 90655, CPT 90656, CPT 90657, CPT 90661, CPT 90662, CPT 90672, CPT 90673, CPT 90674, CPT 90682, CPT…

How To Use cpt 11462

cpt 11462 describes the excision of skin and subcutaneous tissue for hidradenitis in the inguinal region, along with a simple or intermediate repair. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of cpt 11462. 1. What is cpt 11462? cpt 11462 is a code…

Upcoming HCPCS Code Changes

Deleted Codes: J1942 Injection, aripiprazole lauroxil, 1 mg S1090 Mometasone furoate sinus implant, 370 micrograms Revised Codes: J0641 Inj., levoleucovorin, 0.5 mg J2794 Inj., risperdal consta, 0.5 mg J7311 Inj., retisert, 0.01 mg J7313 Inj., iluvien, 0.01 mg Q4122 Dermacell, awm, porous sq cm Q4165 Keramatrix, Kerasorb sq cm Q4184 Cellesta or duo per sq…