office visit established patient cpt code

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.

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List With Office Visit CPT Codes (New & Established Patients)

The CPT codes for office visits can be found in the CPT manual; under range CPT 99202 until 99205 for office visits of new patients . For office visits of established patients, you can use range 99211 to CPT code 99215. We also included CPT 99070 in case you need to bill extra supplies/materials for office visits and CPT code 99072 if extra staff and supplies were needed during a Public Health Emergency.

CPT Code 99070

Long description of CPT 99070 : Supplies and materials [except spectacles] provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided].

Short description: Extra supplies/materials for office visit.

CPT Code 99072

Long description of CPT 99072 : Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service[s], when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

Short description: Extra supplies and staff time for office visits during Public Health Emergency.

CPT Code 99202

Long description of CPT 99202 : 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 time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

Short description: 15-29 minute office visit for new patient evaluation and management.

CPT Code 99203

Long description of CPT 99203 : 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 time for code selection, 30-44 minutes of total time is spent on the date of the encounter.

Short description: 30-44 minute office visit for new patient evaluation and management.

CPT Code 99204

Long description of CPT 99204 : 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 time for code selection, 45-59 minutes of total time is spend on the date of the encounter.

Short description: 45-59 minute office visit for new patient evaluation and management.

CPT Code 99205

Long description of CPT 99205 : 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 time for code+ selection, 60-74 minutes of total time is spent on the date of the encounter.

Short description: 60-74 minute office visit for new patient evaluation and management.

CPT Code 99211

Long description of 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

Short description: Short office visit for established patient management.

CPT Code 99212

Long description of CPT Code 99212 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time spent on the date of the encounter.

Short description: 10-19 minute office visit for established patient management.

CPT Code 99213

Long description of CPT 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.

Short description: 20-29 minute office visit for established patient management.

CPT Code 99214

Long description of CPT 99214 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spend on the date of the encounter.

Short description: 30-39 minutes office visit for established patient management.

CPT Code 99215

Long description of CPT 99215 : Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

Short description: 40-54 minutes office visit for established patient management .

https://www.aapc.com/codes/cpt-codes-range/99211-99215/

https://www.aapc.com/codes/cpt-codes-range/99202-99205/

https://www.aapc.com/codes/cpt-codes/99070

https://www.aapc.com/codes/cpt-codes/99072

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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)

Follow these four steps to code quickly and accurately, while reducing the need to count up data points.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2021;28(4):21-26

Author disclosure: no relevant financial affiliations.

The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest. 1 , 2 To ease the transition, previous FPM articles have laid out the new American Medical Association/CPT medical decision making guide 3 and introduced doctor–friendly coding templates (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), explained how to quickly identify level 4 office visits (see “ Coding Level 4 Visits Using the New E/M Guidelines ,” FPM , January/February 2021), and applied the new guidelines to common visit types (see “ The 2021 Office Visit Coding Changes: Putting the Pieces Together ,” FPM , November/December 2020).

After several months of using the new coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM). Analyzing each note for data points can be time-consuming and sometimes confusing.

That being the case, it's important to understand when you can avoid using data for coding, and when you can't. I've developed a four-step process for this (see “ A step-by-step timesaver ”).

The goal of this article is to clarify the new coding rules and terminology and to explain this step-by-step approach to help clinicians code office visits more quickly, confidently, and correctly.

The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data.

There are different levels of data and different categories within each level, which can make using data to calculate the visit level time-consuming and confusing.

By calculating total time, and then moving on to assessing problems and prescription drug management, most visits can be optimally coded without dealing with data at all.

OFFICE VISIT CODING RULES AND TERMINOLOGY

To make full use of the step-by-step process, we have to first understand the new rules, as well as coding terminology. Here is a brief summary.

Medically appropriate . Physicians and other qualified health care professionals may now solely use either total time or MDM to determine the level of service of an office visit. That means the “history” and “physical exam” components are no longer needed for code selection, which simplifies things. But your patient note must still contain a “medically appropriate” history and physical. So continue to document what is needed for good medical care.

New patient . A new patient is a patient who has not been seen by you or one of your partners in the same medical specialty and the same group practice within the past three years.

Total time and prolonged services . Total time includes all the time you spend on a visit on the day of the encounter (before midnight). It includes your time before the visit reviewing the chart, your face-to-face time with the patient, and the time you spend after the visit finishing documentation, ordering or reviewing studies, refilling medications, making phone calls related to the visit, etc. It does not include your time spent performing separately billed services such as wellness visits or procedures. Total time visit level thresholds differ for new patients vs. established patients. (See the total times in “ The Rosetta Stone four-step template for coding office visits .”)

The prolonged services code comes into play when total time exceeds the limits set for level 5 visits by at least 15 minutes.

Medical decision making . MDM is made up of three components: problems, data, and risk. Each component has different levels, which correspond to levels of service (low/limited = level 3, moderate = level 4, and high/extensive = level 5). The highest level reached by at least two out of the three components determines the correct code for the level of service. MDM criteria is the same for new and established patients.

Problems addressed . This includes only the problems you address at that specific patient visit. It does not include all the patient's diagnoses and does not include problems that are exclusively managed by another clinician. Problems addressed are separated into low-complexity problems (level 3), moderate-complexity problems (level 4), and high-complexity problems (level 5). To code correctly, you need to know the coding value of the problems you address. It is helpful to think of problems in terms of levels of service (e.g., a sinus infection is usually a level 3 problem, and pneumonia or uncontrolled diabetes are usually level 4 problems).

The simplest way to summarize problems is this: Life-threatening problems are level 5; acute or chronic illnesses or injuries are level 3 or 4 depending on how many there are, how stable they are, and how complex they are; and if there's just one minor problem, it's level 2.

(For more specifics see “ What level of problem did I address? ”)

Risk . Risk is also separated into “low” (level 3), “moderate” (level 4), and “high” (level 5) categories.

Level 3 risk includes the use of over-the-counter (OTC) medications.

Level 4 risk includes the following:

Prescription drug management: starting, stopping, modifying, refilling, or deciding to continue a prescription medication (and documenting your thought process),

Social determinants of health that limit diagnosis or treatment (this is when patients' lack of finances, insurance, food, housing, etc., affects your ability to diagnose, manage, and care for them as you normally would).

Level 5 risk includes the following:

Decisions about hospitalization,

Decisions about emergency major surgery,

Drug therapy that requires intensive toxicity monitoring,

Decisions to not resuscitate or to de-escalate care because of poor prognosis.

Data analyzed . For purposes of MDM, data is characterized as “limited” (level 3 data), “moderate” (level 4 data), or “extensive” (level 5 data). But each level of data is further split into Categories 1, 2, and 3. This can make calculating data complicated, confusing, and time-consuming. Here are the data components and terms you need to know.

Category 1 data includes the following:

The ordering or reviewing of each unique test , i.e., a single lab test, panel, X-ray, electrocardiogram (ECG), or other study.

Ordering and reviewing the same lab test or study is worth one point, not two; a lab panel (e.g., complete blood count or comprehensive metabolic panel) is worth one point,

Reviewing a pertinent test or study done in the past at your own facility or another facility,

Reviewing prior external notes from each unique source, including records from a clinician in a different specialty or from a different group practice or facility as well as each separate health organization (e.g., reviewing three notes from the Mayo Clinic is worth one point, not three, but reviewing one note from Mayo and one from Johns Hopkins is worth a total of two points),

Using an independent historian, which means obtaining a history from someone other than the patient, such as a parent, spouse, or group home staff member. (This is included in Category 2 for level 3 data, but falls into Category 1 for level 4 and 5 data.)

Category 2 data includes the following:

Using an independent historian (for level 3 data only),

Independent interpretation of tests, which is your evaluation or reading of an X-ray, ECG, or other study (e.g., “I personally reviewed the X-ray and it shows …”) and can include your personal evaluation of a pertinent study done in the past at your or another facility. It does not include reviewing another clinician's written report only, and it does not include studies for which you are also billing separately for your reading.

Category 3 data includes the following:

Discussion of patient management or test interpretation with an external physician, other qualified health care professional, or appropriate source. An external physician or other qualified health care professional is someone who is not in your same group practice or specialty. Other appropriate sources could include, for example, consulting a patient's teacher about the patient's attention deficit hyperactivity disorder.

A STEP-BY-STEP TIMESAVER

The majority of office visits can be optimally coded by using time or by looking at what level of problems were addressed (see Steps 1 and 2 below) and whether a prescription medication was involved.

A level 3 problem can be coded as a level 3 visit if you address it with an OTC or prescription medication. A level 4 problem can be coded as a level 4 visit if you order prescription medication or perform any other type of prescription drug management (modifying, stopping, or deciding to continue a medication). Most level 2 and level 5 office visits are straightforward, and most level 5 visits will be coded by time. They will typically be visits in which you address multiple problems or complicated problems and the total time exceeds 40 minutes for established patients. This is much more common than seeing critically ill patients who may require admission, which is another level 5 scenario. The few remaining patient visits that have not already been coded require analyzing data (Steps 3 and 4). (See “ The Rosetta Stone four-step template for coding office visits .”)

Step 1: Total time . Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to Step 2.

Step 2: “Problems plus.” Don't be afraid to move on from time-based coding if you believe you performed a higher level visit using MDM. Many visits can be coded with MDM just by answering these two questions: What was the highest-level problem you addressed during the office visit? And did you order, stop, modify, or decide to continue a prescription medication?

If you addressed a level 2 problem and your total time was less than 20 minutes (or less than 30 for a new patient), then code level 2.

If you addressed a level 3 problem, plus you recommended an OTC medication or performed prescription drug management, then code level 3.

If you addressed a level 4 problem, plus you performed prescription drug management, then code level 4.

Chronic disease management often qualifies as level 4 work. For documentation, think “P-S-R”: problem addressed, status of the problem (stable vs. unstable), and prescription drug management (Rx). This trio should make it clear to coders, insurance companies, and auditors that level 4 work was performed.

For instance, if a patient has controlled hypertension and diabetes and you document that you decided to continue the current doses of losartan and metformin, that's level 4 (two stable chronic illnesses plus prescription drug management). If you see a patient with even one unstable chronic illness and document prescription drug management to address it, that's also level 4.

For a level 5 problem, if you see a really sick patient and decide to admit or consider admission (and you document your thought process in your note), then code level 5.

By starting with total time and, if necessary, moving on to “problems plus,” you will probably be able to optimally code 90% of your office E/M visits. But on the rare occasions when you see a patient for level 4 or 5 problems for less than the required time and don't do any prescription drug management, you may have to proceed to Steps 3 and 4.

Step 3: Level 4 problem with simple data or social determinants of health concerns . Code level 4 if you saw a patient for a level 4 problem and did any of the following:

Personally interpret a study (e.g., X-ray),

Discuss management or a test with an external physician,

Modify your workup or treatment because of social determinants of health.

Step 4: Level 4 or 5 problem with complex data . If you saw a patient for a level 4 problem and still haven't been able to code the visit at this point, you have to tally Category 1 data points:

Review/order of each unique test equals one point each,

Review of external notes from each unique source equals one point each,

Use of an independent historian equals one point.

Once you reach three points, code it as level 4.

For a level 5 problem, if you see a really sick patient, order/interpret an X-ray or ECG, and review/order two lab tests, then code level 5.

Following these steps should allow you to quickly identify the optimal level to code most any E/M office visit (for pre-op visits, see “ Coding pre-ops template .”)

Here's a catchy rhyme to remember the basic outline of the steps:

To finish fast ,

code by time and problems first ,

and save data for last .

By mastering the new coding rules and terminology and applying this four-step approach, you can code office visits more quickly, accurately, and confidently — and then spend more time with your patients and less time at the computer.

CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes . American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

E/M Office Visit Compendium 2021. American Medical Association; 2020.

Table 2 – CPT E/M office revisions level of medical decision making. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

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