office visit cpt codes 99205

Welcome to our article on CPT Code 99205, the evaluation and management code used for high-level services for new patients. In this section, we will provide a comprehensive description of CPT code 99205 and its significance in medical billing and reimbursement processes.

Key Takeaways:

• CPT Code 99205 is an office or outpatient visit code used for the evaluation and management of new patients.
• It requires a comprehensive history, a comprehensive examination, and high medical decision-making.
• This code is used for patients with acute or chronic conditions that pose an immediate threat to life or physical function.
• The reimbursement rate for Medicare in 2022 is $244.99.

CPT Code 99205 Billing Guidelines

When using CPT code 99205, it is important to follow specific guidelines to ensure accurate billing and coding. The guidelines for CPT code 99205 include the following criteria:

• A high level of medical decision-making: The medical decision-making involved in the evaluation and management of a patient must be of a high complexity. This includes the analysis and interpretation of medical records, diagnostic tests, and any other relevant information to determine the diagnosis and treatment plan.
• A medically appropriate history or examination: A comprehensive history or examination is necessary to assess the patient’s condition properly. This includes gathering information about the patient’s medical history, current symptoms, previous treatments, and any other factors relevant to their healthcare.
• A typical session length of 60-74 minutes: CPT code 99205 is associated with a longer duration of service compared to other evaluation and management codes. The session length includes both face-to-face and non-face-to-face time spent on the patient encounter.

The complexity of medical decision-making and the level of care required play a significant role in determining the appropriate use of CPT code 99205. It is crucial to choose this code based on the length of service and the complexity of the medical decision-making involved. Proper documentation of these factors is necessary to support the use of CPT code 99205 in billing and coding processes.

Example of CPT Code 99205 Billing Guidelines:

Cpt code 99205 reimbursement.

In this section, we will discuss the reimbursement details for CPT Code 99205. It is important for healthcare providers to understand the reimbursement rates associated with this code to ensure accurate billing and proper reimbursement.

The reimbursement rate for CPT Code 99205 is $244.99 for Medicare in 2022. However, it is crucial to note that reimbursement rates may vary depending on the payer and other factors. Therefore, it is essential to stay updated on any changes or updates in reimbursement rates.

To ensure accurate billing and reimbursement, we recommend consulting with a medical billing service. These services have expertise in navigating the complexities of medical billing and can assist providers in maximizing reimbursement for CPT Code 99205.

Below is a summary of the reimbursement details for CPT Code 99205:

As mentioned earlier, the reimbursement rates can vary for private insurance payers. It is advisable to check with individual insurance companies to determine the specific reimbursement rates for CPT Code 99205.

Using a medical billing service can be beneficial in ensuring accurate billing and optimizing reimbursement for CPT Code 99205. These services have the expertise and knowledge to navigate the complexities of medical billing, including understanding reimbursement rates and coding guidelines.

We understand the importance of accurate billing and reimbursement for healthcare providers. By staying updated on reimbursement rates and utilizing medical billing services, healthcare providers can ensure proper reimbursement for the services they provide.

CPT Code 99205 Documentation Requirements

When billing for the CPT code 99205, it is vital to adhere to the documentation requirements. These requirements ensure accurate coding and billing practices for high-level evaluation and management services. The following documentation elements must be included:

1. Comprehensive History

A comprehensive history refers to a detailed account of the patient’s medical background, including their past medical, surgical, social, and family history. This information helps evaluate the patient’s overall health status and assess the severity of their condition.

2. Comprehensive Examination

A comprehensive examination involves a thorough assessment of the patient’s physical condition. It includes a systematic evaluation of body systems, such as cardiovascular, respiratory, musculoskeletal, and neurologic systems, among others. This examination aids in determining the extent and severity of the patient’s illness or injury.

3. High Medical Decision-Making

High-level medical decision-making refers to the complex thought process healthcare providers employ when establishing a diagnosis, formulating a treatment plan, and managing the patient’s healthcare. It involves factors such as analyzing test results, consulting with other healthcare professionals, and considering the risks and benefits of different treatment options.

Additionally, it is essential to clearly document the complexity and severity of the patient’s condition, along with any diagnostic tests ordered and the management plan. By fulfilling these documentation requirements, healthcare providers can ensure accurate coding and billing for CPT code 99205.

CPT Code 99205 Time Length

The time length for a CPT code 99205 session is typically 60-74 minutes. This includes both face-to-face and non-face-to-face time spent on the patient encounter. It is crucial to accurately document the time spent with the patient to ensure correct coding and billing.

Factors Affecting Time Length:

• Comprehensive History: Taking a detailed medical history from the patient.
• Comprehensive Examination: Conducting a thorough physical examination.
• Medical Decision-Making: Assessing the complexity of the patient’s condition and determining the appropriate treatment plan.
• Coordination of Care: Communicating with other healthcare professionals involved in the patient’s care.

Accurately documenting the time spent during each of these components is essential for proper coding and billing.

It is important to note that the total time may vary based on the complexity of the patient’s condition and the individual provider’s workflow.

CPT Code 99205 vs Other E&M Codes

When it comes to evaluating and managing new patients, CPT code 99205 is considered the highest level of care. It requires a meticulous and thorough approach, with a particular focus on high-level medical decision-making. This code is reserved for patients with severe exacerbations or progressions of chronic illnesses or acute conditions that pose a significant threat to life or bodily function.

However, it’s important to note that there are other evaluation and management (E&M) codes available for new patients, each with its own set of documentation requirements and complexity levels. Let’s take a closer look at some of these codes:

CPT Code 99202

CPT code 99202 is used for a new patient office or outpatient visit that requires a problem-focused history, a problem-focused examination, and straightforward medical decision-making. It is typically utilized for patients with minor illnesses or injuries.

CPT Code 99203

For new patients who require a more extensive evaluation and management, CPT code 99203 is applicable. It involves an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity. This code is often used for patients with moderate illnesses or injuries.

CPT Code 99204

CPT code 99204 takes the evaluation and management of new patients a step further. It requires a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. This code is commonly used for patients with complex or multiple health issues.

CPT Code 99215

Unlike CPT code 99205, which is reserved for the most severe cases, CPT code 99215 is used for established patients who require a comprehensive level of care. It entails a comprehensive history, a comprehensive examination, and high-level medical decision-making. This code is often used for patients who have experienced significant exacerbations or progressions of chronic illnesses.

It’s crucial to select the appropriate E&M code based on the patient’s condition and the level of care provided. This ensures accurate coding, proper reimbursement, and compliance with billing guidelines. Consulting a medical coding professional can help navigate the complexities and nuances of E&M coding.

CPT Code 99205 Changes in 2021

Significant changes were made to the way physicians document and code outpatient evaluation and management services starting on January 1, 2021. Physicians billing for Medicare patients no longer need to use documentation of a patient’s history or physical examination to determine the appropriate level of E/M coding. Instead, physicians can choose between time or medical decision-making to determine code selection.

New Documentation Guidelines

Prior to the changes in 2021, physicians were required to meet specific documentation criteria, including a detailed history or comprehensive examination, to determine the appropriate E/M code. However, these guidelines have been simplified to allow for greater flexibility and efficiency in coding.

Time-Based Coding

Under the new guidelines, physicians now have the option to select the appropriate code based on the time spent on the patient encounter. For CPT code 99205, the typical session length is 60-74 minutes. This includes both face-to-face and non-face-to-face time spent on the patient’s care. It is important to accurately document the time spent with the patient to ensure correct coding and billing.

Medical Decision-Making

Alternatively, physicians can determine the E/M code based on the level of medical decision-making involved in the patient’s care. This includes the complexity of the patient’s condition, the amount and/or complexity of medical data reviewed, and the risk of complications or morbidity. The documentation must clearly demonstrate the medical necessity and level of decision-making involved in the patient’s treatment.

Implications for Billing and Reimbursement

These changes in documentation and code selection have implications for billing and reimbursement. It is important for healthcare providers and medical billing staff to understand the new guidelines and ensure accurate coding and documentation. By properly documenting the time spent with the patient or the level of medical decision-making, healthcare providers can avoid coding errors and potential issues with reimbursement.

To illustrate the changes in code selection and documentation requirements, refer to the following table:

The new guidelines provide healthcare providers with more flexibility in coding and documentation while still ensuring accurate and appropriate payment for services rendered. It is essential to stay updated on coding changes and consult with billing and coding experts to navigate the complexities of medical billing.

For a visual representation of the code changes in 2021, refer to the image below:

CPT Code 99205 Medical Necessity

CPT code 99205 is an important evaluation and management code that should be used when reporting services provided to the sickest patients. It is crucial to understand the medical necessity criteria for using this code appropriately.

Medical necessity is a key factor in determining whether the use of CPT code 99205 is justified. It should only be used for patients whose conditions pose an immediate threat to life or physical function. This code is not suitable for ongoing stable conditions that do not present a serious risk to the patient.

When determining the medical necessity of using CPT code 99205, healthcare providers must thoroughly evaluate the severity, complexity, and urgency of the patient’s condition. The documentation should clearly demonstrate the immediate threat the patient faces, ensuring that the highest level of care is necessary to address their medical needs.

Using CPT code 99205 without proper medical necessity can lead to billing inaccuracies and potential repercussions from payers. It is crucial to accurately assess the patient’s condition and select the appropriate code that aligns with their medical needs.

To help illustrate the medical necessity requirements for CPT code 99205, the following table highlights the key factors to consider:

By carefully assessing the medical necessity of CPT code 99205, healthcare providers can ensure appropriate coding and billing, resulting in accurate reimbursement for the services rendered.

CPT Code 99205 Reimbursement Changes

The reimbursement rates for CPT code 99205 have undergone significant changes for 2021. The new relative value units (RVUs) have increased compared to the previous year, resulting in higher reimbursement rates for healthcare providers. The specific rate increase ranges from 6.5% to 30.5% depending on the particular code.

Staying informed about reimbursement changes is vital for accurate billing and reimbursement. As medical billing professionals, we understand the importance of keeping up with the updated rates to optimize revenue for healthcare practices.

Reimbursement Rate Comparison

Below is a comparison table of the reimbursement rates for CPT code 99205 before and after the changes in 2021. The table provides a clear overview of the percentage increase in reimbursement rates.

Table: Comparison of CPT Code 99205 Reimbursement Rates Before and After the 2021 Changes

Based on the reimbursement rate changes, healthcare providers can expect increased financial returns for services rendered using CPT code 99205. However, it is essential to ensure accurate billing and reimbursement by implementing updated coding practices and staying informed about any future changes to reimbursement rates.

CPT Code 99205 Medical Billing Services

At Medical Bill Gurus, we specialize in providing comprehensive medical billing services for healthcare providers. Our president, Daniel Lynch, is an expert in medical billing services and has extensive experience working with all insurance payers, including Medicare. We offer a range of services to ensure accurate and efficient billing processes for our clients.

Our Medical Billing Services

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With our comprehensive suite of services, we take care of the entire billing process, allowing healthcare providers to focus on delivering quality care to their patients. We understand the complexities of medical billing and keep up-to-date with the latest changes and regulations to ensure accurate and compliant billing.

One of the key advantages of partnering with us is our month-by-month contract. We believe in earning your trust and providing top-notch services that meet your specific needs. We also offer a free account setup to make the transition to our services seamless and hassle-free.

With Medical Bill Gurus, you can trust that your medical billing needs are in capable hands. Our team of experts is dedicated to maximizing your revenue and streamlining your billing processes. Contact us today to learn more about our services and how we can help you optimize your medical billing.

CPT Code Lookup for 99205

When it comes to reporting office or other outpatient visits for new patients, healthcare providers rely on CPT code 99205. This code is used for the evaluation and management of new patients with acute or chronic conditions that pose an immediate threat to life or physical function. To ensure accurate coding and billing, it is crucial to use a reliable CPT code lookup tool.

CPT code 99205 requires comprehensive documentation, including a comprehensive history, a comprehensive examination, and high medical decision-making. Healthcare providers must carefully assess the patient’s condition and accurately document the level of medical decision-making involved to properly assign this code.

Using a CPT code lookup tool simplifies the process of finding the appropriate code for office or outpatient visits. These tools provide a searchable database of CPT codes, allowing healthcare providers to quickly find the specific code they need without the risk of errors or inaccuracies. By entering relevant keywords such as “cpt code 99205” or “cpt code lookup,” healthcare providers can easily access the information they need.

With the help of a reliable CPT code lookup tool, healthcare providers can ensure proper coding, reduce the risk of claim rejections, and maximize reimbursement. By accurately documenting and coding for the evaluation and management services provided to new patients, healthcare providers can effectively communicate the complexity and severity of the patient’s condition.

Using the accurate CPT code 99205 ensures that healthcare providers are properly compensated for their services and reflects the complexity and severity of the patient’s condition. By utilizing a CPT code lookup tool, healthcare providers can streamline the coding process, enhance accuracy, and optimize reimbursement.

Next, we will delve into the overview of CPT code 99205 to gain a better understanding of its requirements and importance in medical billing.

CPT Code 99205 Overview

CPT code 99205 is a high-level evaluation and management code used for new patients. It requires a comprehensive history, a comprehensive examination, and high medical decision-making. The typical session length is 60-74 minutes. This code is used for patients with acute or chronic conditions that pose an immediate threat to life or physical function.

Key Points:

• CPT code 99205 is a high-level evaluation and management code for new patients.
• The typical session length is 60-74 minutes.

CPT code 99205 plays a vital role in the accurate billing of high-level evaluation and management services for new patients. Health care providers must ensure comprehensive documentation, high-level medical decision-making, and adherence to a typical session length of 60-74 minutes. To ensure proper reimbursement and avoid any compliance issues, it is crucial to stay updated on the latest billing guidelines, documentation requirements, and reimbursement changes.

Navigating the complexities of medical billing can be challenging for providers. That’s where medical billing services like Medical Bill Gurus can provide valuable expertise and support. By partnering with a reputable medical billing service, providers can streamline their billing process, reduce errors, and optimize their revenue cycle management. Medical Bill Gurus specializes in medical billing services for all insurance payers, including Medicare, and offers a comprehensive range of services such as daily claims filing, claim processing, eligibility verification, appeals and denials management, and more.

Efficient medical billing practices are essential for healthcare providers to maintain financial stability and ensure timely and accurate reimbursement. By leveraging the expertise of medical billing professionals and staying informed about changes in the healthcare industry, providers can focus on delivering quality care while maximizing their revenue potential.

What is CPT code 99205?

CPT code 99205 is an office or outpatient visit code used for the evaluation and management of a new patient with comprehensive history, examination, and high medical decision-making.

What are the billing guidelines for CPT code 99205?

The billing guidelines for CPT code 99205 include a comprehensive history, examination, and high medical decision-making. The patient’s condition must be acute or chronic and pose an immediate threat to life or physical function.

How is CPT code 99205 reimbursed?

The reimbursement rate for CPT code 99205 is 4.99 for Medicare in 2022. However, reimbursement rates may vary depending on the payer and other factors.

What are the documentation requirements for CPT code 99205?

The documentation requirements for CPT code 99205 include a comprehensive history, examination, high medical decision-making, clear documentation of the patient’s condition, diagnostic tests ordered, and the management plan.

What is the time length for a CPT code 99205 session?

The typical time length for a CPT code 99205 session is 60-74 minutes, including both face-to-face and non-face-to-face time with the patient.

How does CPT code 99205 compare to other E&M codes?

CPT code 99205 is the highest level of evaluation and management code for new patients, while other E&M codes like 99202, 99203, 99204, and 99215 have different documentation requirements and levels of complexity.

What changes were made to CPT code 99205 in 2021?

Significant changes were made to the way physicians document and code outpatient evaluation and management services starting on January 1, 2021, allowing physicians to choose between time or medical decision-making to determine code selection.

When is the use of CPT code 99205 justified?

CPT code 99205 should only be used when reporting services provided to the sickest patients whose conditions pose an immediate threat to life or physical function. It is inappropriate to use this code for ongoing stable conditions.

Are there reimbursement changes for CPT code 99205?

Yes, reimbursement rates for CPT code 99205 have changed for 2021, with increased relative value units compared to the previous year. However, it is important to stay updated on reimbursement changes as they can vary.

What medical billing services are available for CPT code 99205?

Medical Bill Gurus is a medical billing company that offers services for healthcare providers, including daily claims filing, eligibility verification, and more. They specialize in medical billing services for all insurance payers, including Medicare.

How can I perform a CPT code lookup for 99205?

To perform a CPT code lookup for 99205, you can utilize an accurate CPT code lookup tool to ensure correct coding and billing.

Can you provide an overview of CPT code 99205?

CPT code 99205 is a high-level evaluation and management code used for new patients with comprehensive history, examination, and high medical decision-making. It is used for patients with acute or chronic conditions that pose an immediate threat to life or physical function.

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A mental health billing service, cpt code 99205: billing guide & reimbursement rates [2024].

In our guide to CPT Code 99205, we’ll teach you about this straightforward complexity evaluation and management procedure code, 99205 guidelines for billing, and the CPT Code 92205 reimbursement rate for Medicare in 2024.

If you hate billing, consider reaching out to our mental health billing service at TheraThink for help.  If you love billing, please read on!

CPT Code 99205 Definition

99205 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 medical decision making.

CPT Code 99205 Reimbursement Rate (Medicare, 2024): $216.77

In the past years, this E/m code has been paid $224.36 by Medicare in 2021. ( Source )

CPT Code 99205 Time Length: 60 – 74 Minutes

An average session length for an initial 99205 evaluation and management session is around 65 minutes.

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99205 Billing Guidelines:

Using CPT code 99205 requires a medical decision making level of high with a medically appropriate history or examination.

“In 2021, new patient codes 99202-99205 no longer require the three key components or reference typical face-to-face time. Instead, each service includes “a medically appropriate history and/or examination,” and code selection is based on the MDM [medical decision making] level or total time spent on that date.”

This decision was made on 1/1/2021 to update the descriptor for Group 1 CPT and HCPCS codes 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215.

Pick the code that is based on the length of service and complexity of medical decision making and appropriate level of care required.

99205 Requirements:

• Medical decision making:  high
• Time length: 60 – 74 Minutes
• Evaluation of clinical history and examinations

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

99205 CPT Code (2023) | Description, Reimbursement, Modifier & Examples

The 99205 CPT code can be reported for office or other outpatient visits of a new patient . The estimated time is between 60 and 74 minutes. This procedure can be billed with modifier 25 and the RVU is 3.50 since 2021.

99205 CPT Code Description

CPT 99205 can be billed for office or other outpatient visits of a new patient.

Report CPT code 99205 for office or other outpatient visit for the evaluation and management of a new patient which requires:

• medically appropriate history; or/and
• examination and a high level of medical decision making.

How Many Minutes Is The 99205 CPT Code?

Procedure 99205 is estimated between 60 and 74 minutes. The total time needs to be spent on the date of encounter.

If the procedure exceeds 74 minutes; bill prolonged services ( CPT 99354 – CPT 99357).

Guidelines For Time

Revision of time means the total time spent with the patient on the date of the encounter, that recognises face to face and important non face to face activities.

Clear time ranges for each code should be documented with easy to remember increments.

When the visit dominates counselling and/or coordination of care, time should ONLY be used for selecting the E&M level. 

However, time may be used whether or not counselling and/or coordination of care dominates the service.

Time could be counted for any relevant activities that are not separately reported, starting from preparation to see patient, obtaining history & documenting in medical records, reviewing tests or history, managing the patient by ordering of test, medicines or procedures performing medically necessary examination and/or evaluation, counselling and educating the patient or caretakers or family, interpreting tests or any care coordination.

Note: Do not count time spent on travel, separately reported services or general discussion for management of a patient

How Many RVU Do I Need For 99205?

The RVU for the 99205 CPT code have increased to 3.50 in 2021 form 3.17 in 2020.

99205 CPT Code Reimbursement

CPT 99205 will only be reimbursed if the patient is a new patient. This procedure code means high or level 5 office visit and details of the documentation matters to qualify as “reasonable and necessary”.

High complexity or high severity means the risk of death is high without treatment or a probability of severe, prolonged functional or organ impairment. 

The 99205 CPT code can only be coded if the number and complexity of problems is high. To determine if the number of complexity is high the following needs to be confirmed.

The number of acute or/and chronic conditions or injury needs to be the same or more with severe exacerbation or side effects of treatment.

The clinical notes have to reflect that illness or injury poses a threat to patient’s life or bodily function in the near term without treatment.

The amount or/and complexity of data (ACOD) to be reviewed and analysed needs to be extensive in order to bill CPT 99205.

Analysed means the test itself may not be subject to analysis. However, the test is deemed in the thought process of the physician for diagnosis, evaluation or treatment. 

To determine ACOD to be extensive at least 2 out of 3 categories must be met to meet the requirements.

Category 1 

Order Tests – Ordering of each unique test. Data reviewed by physician: 

• prior external note/notes;
• result/results of each unique test.

Assessment requiring an independent historian/historians. For example: patient unable to talk or unconscious/disoriented

Category 2 

Independent interpretation of tests performed by another physician/QHP (not separately reported).

For example: Radiology bill with modifier 26 if billed separately can not be considered for counting as it is already billed.

Discussion of management or test interpretation.

For example: Discussion with pathologist or a specialist or QHP that are not billed separate.

Note 1: An external physician or other qualified health care professional means who is practicing independently or who is not in the same group practice or from different speciality.

Note 2 : Discussion need not be on same day and may not be face to face, but is counted only once in MDM.

CPT 99205 With Modifier 25

When a minor surgery is performed on the same day as an E&M, separate documentation is required to provide evidence that a separately identifiable service was performed other than the procedure.

The billing should be modified using modifier 25 with the 99205 CPT code for separate reimbursement. 

For example : New patient, 70 year old male comes in to the outpatient with a head injury. The physician examines the laceration on the scalp and repairs with intermediate sutures.

During the examination, there is an abrupt change in the neurological status of patient with vomiting. The physician orders immediate admission. 

The visit involves minor procedure of laceration repair and distinct evaluation and decision making for the neurological status.

This qualifies the visit to be billed as 99205 CPT with Modifier 25 to receive the payment for wound repair and the E&M service.

The 99205 CPT code can be billed for the examples underneath.

A 65 year old female new patient, comes in after a fall, with severe pain in left hip region. Patient is a smoker and diabetes , has venous insufficiency and chronic edema of both legs with redness.

Physician orders X ray of hip and interprets the finding as communited fracture of the neck of femur.

Physician plan immediate hospitalization. Physician also discusses with the patient on smoking cessation, glycemic target adherence, the importance of elevating his leg to decrease edema, wearing compression stockings for venous insufficiency and the risks of pulmonary embolus for 65 minutes

Answer: CPT 99205 as the discussion and counselling dominates the high risk visit

Initial office visit for a patient with disseminated lupus erythematosus with kidney disease, edema, purpura, and scarring lesions on the extremities plus cardiac symptoms. (Dermatology/General Surgery/Internal Medicine)

Initial office visit for a 25-years-old female with systemic lupus erythematosus, fever , seizures, and profound thrombocytopenia . (Rheumatology/Allergy & Immunology) 

Initial office visit for an adult with multiple cutaneous blisters, denuded secondarily infected ulcerations, oral lesions, weight loss , and increasing weakness refractory to high does corticosteroid.

Initiation of new immunosuppressive therapy. (Dermatology)

Initial office visit for a 28-years-old male with systemic vasculitis and compromised circulation to the limbs. (Rheumatology)

Initial office visit for a 41-years-old female new to the area requesting rheumatologic care, no disability due to scleroderma and recent hospitalization for malignant hypertension. (Rheumatology)

Initial office visit for a 52-years-old female with acute four extremity weakness and shortness of breath one weak post-fly vaccination. (Physical Medicine & Rehabilitation)

Initial office visit for a 60-years-old male previous back surgery; now presents with back and pelvic pain, two-month history of bilateral progressive calf and thigh tightness and weakness when walking, causing several falls. (Orthopaedic Surgery)

Initial office visit for an adolescent referred from emergency room after making suicide gesture. (Psychiatry)

Initial Office visit for a 49-years-old female with a history of headaches and dependence on opioids, She reports weight loss, progressive headache, and depression. (Psychiatry)

Initial office visit for a 50-years-old female with symptoms of rash, swelling, recurrent arthritic complaints, and diarrhea and lymphadenopathy.

Patient has had a 25 lb weight loss and was recently camping in the Amazon. (Allergy & Immunology).

Initial office visit for a 34-years-old uremic Type I diabetic patient referred for ESRD modality assessment and planning. (Nephrology)

Initial office visit for a 75-years-old female with neck and bilateral shoulder pain, brisk deep tendon reflexes, and stress incontinence. (Physical Medicine & Rehabilitation)

Initial office visit for an 8-years-old male with cerebral palsy and spastic quadriparesis. (Physical Medicine & Rehabilitation)         

Initial office visit for a 73-years-old male with known prostate malignancy, who presents with sever back pain and a recent onset of lower extremity weakness . (Physical Medicine & Rehabilitation)

Initial office visit for a 38-years-old male with paranoid delusions and a history of alcohol abuse. (Psychiatry)

Initial office visit for a 12-weak-old with bilateral hip dislocations and bilateral club feet. (Orthopaedic Surgery)

Initial office visit for a 29-years-old female with acute orbital congestion, eyelid retraction, and bilateral visual loss from optic neuropathy. (Ophthalmology)

Initial office visit for a 70-years-old diabetic patient with progressive visual field loss, advanced optic disc cupping, and neovascularization of retina. (Ophthalmology)

Initial office visit for a newly diagnosed Type I diabetic patient. (Endocrinology)

Initial office evaluation of a 65-years-old female with exertional chest pain , intermittent claudication, syncope , and a murmur of aortic stenosis. (Cardiology)

Initial office visit for a 73-years-old male with an unexplained 20 lb weight loss. (Hematology/Oncology)

Initial office evaluation, patient with systemic lupus erythematosus, fever, seizures, and profound thrombodytopenia. (Allergy & Immunology/Internal Medicine/Rheumatology)

Initial office evaluation and management of patient with systemic vasculitis and compromised circulation to the limbs. (Rheumatology)

Initial office visit for a 24-year-old homosexual male who has a fever, a cough, and shortness of breath. (Infection Disease)

Initial outpatient evaluation of a 69-years-old male with sever chronic obstructive pulmonary disease, congestive heart failure , and hypertension. (family Medicine)

Initial office visit for a 17-years-old female, who is having school problems and has told a friend that she is considering suicide, The patient and her family are consulted in regard to treatment options. (Psychiatry)   

Initial office visit for a female with severe hirsutism, amenorrhea , weight loss, and a desire to have children. (Endocrinology/Obstetrics & Gynecology)       

Initial office visit for a 42-year-old male on hypertensive medication, newly arrived to the area, with diastolic blood pressure of 110, history of recurrent calculi, episodic headaches, intermittent chest pain, and orthopnea. (Internal Medicine)

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How to Code for Telehealth, Audio-Only, and Virtual-Digital Visits 

Learn how to accurately get paid for telemedicine services with medical codes for telehealth, audio-only, and virtual-digital visits.

Looking for additional telemedicine coding resources?

Coding for Telehealth Visits

Note:  These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments. 

How do I code a new or established patient telehealth office visit that uses audio-video communications technology?

* Elevance's  policies vary by state; contact your provider-relations representative.

Coding for Audio-only Visits

How do i code an audio-only visit for a new or established patient .

CPT Codes: 99441-99443 

Audio-only scenario notes 

Medicare requires audio-video for most office visit evaluation and management (E/M) services (CPT codes 99202-99215) telehealth services. Audio-only encounters are allowed for certain services. Eligible services may be found on the Medicare Telehealth Services list. Medicare allows audio-only telehealth services for office visit E/M services (CPT codes 99202-99215) for the treatment of mental health conditions.   

UHC states they will consider payment for eligible audio-only services listed in Appendix P of the CPT book. Eligible services must be reported using either POS 02 or 10 and include the -93 modifier. CPT codes billed with modifier -93 that are not in Appendix P will not be considered for payment.   

Private payers vary on covered telehealth services. Check with your provider relations representatives for each payer’s telehealth policy and covered telehealth services. 

CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443) through the end of calendar year 2023. Other services that may be provided via audio-only are available on the Medicare Telehealth List. 

Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment. 

The following codes may be used by physicians or other qualified health professionals who may report E/M services: 

• 99441: telephone E/M service; 5-10 minutes of medical discussion 
• 99442: telephone E/M service; 11-20 minutes of medical discussion 
• 99443: telephone E/M service, 21-30 minutes of medical discussion 

Telephone E/M services should not be reported when the time spent on the telephone is captured in other services reported, such as: 

• if CPT codes 99421-99423 have been reported by the same physician in the previous seven days for the same problem, 
• when CPT codes 99339-99340 and 99374-99380 are used for the same call, 
• during the same month with CPT codes 99487 and 99489, and 
• when performed during the same service period at CPT codes 99495-99496. 
• Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies.  

Coding for Virtual-Digital Visits 

How do i code an e-visit (cpt 99421-99423) for an established patient .

CPT Codes: 99421-99423 

How do I code a virtual check-in (HCPCS codes G2012 and G2010) for an established patient? 

HCPCS Codes: G2012, G2252, G2010 

Virtual/Digital Scenario Notes 

• Patient consent is required and may be obtained either before or at the time of service. 
• Virtual check-ins and e-visits must technically be initiated by a patient; however, physicians and other providers may need to educate beneficiaries on the availability of the service prior to patient initiation. 
• There are no POS or modifier requirements for virtual check-ins or e-visits. Use the POS used for typical services. 

Virtual Check-in (HCPCS Code G2012, G2252) 

• These are brief conversations with a physician or other clinician to determine if an in-person visit is necessary. 
• The communication cannot be related to a medical visit within the previous seven days and cannot lead to medical visit within the next 24 hours (or soonest appointment available). 
• Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal. 
• HCPCS code G2010 can be used when a captured video or image (store and forward) is sent to the physician. The physician must follow up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment). 

E-Visits (online digital evaluation and management services) 

• These are non-face-to-face, patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period, and the exchange must be stored permanently. 
• Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans (including generation of prescriptions or ordering of tests), and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication 

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes:

• 99421: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 
• 99422: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes 
• 99423: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 

E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient. Additionally, e-visits should not be billed when using the following codes for the same communication: 

• 99339-99340 
• 99374-99380 
• 99487 and 99489 
• 99495-99466 

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