what is E & M SERVICES

Evaluation and Management Services

According to Medicare’s Documentation Guidelines for Evaluation and Management Services, a level-3 established patient office visit requires medical decision making of low complexity. Moderate-complexity decision making is required for a level-4 encounter. Before you can distinguish between the two, you must understand that the level of medical decision making in a patient encounter is based on three parameters: the problems addressed, the data reviewed and the level of risk.


The problems and data are evaluated using a system of weighted points depicted in the tables. These tables were developed by the Centers for Medicare & Medicaid Services and distributed to all Medicare carriers to be used on a voluntary basis; although widely used, they are not part of the official E/M guidelines.

An encounter earns points based on the number and type of problems addressed. For example, an encounter with a patient whose chronic illness is stable would be worth one “problem” point, while an encounter involving a patient with a new problem for which additional work-up is planned would be worth four points. The data table works similarly, with different numbers of points available depending on the type of data and the nature of the review. For example, reviewing or ordering a clinical lab test is worth one point, while reviewing and summarizing old patient records is worth two.

The risk table is identical to the one in the E/M guidelines. It only takes one element from any of the three categories listed in the table (presenting problems, diagnostic procedures and selected management options) to qualify for a particular level of risk. The documentation guidelines explicitly state that the physician should use the highest level of risk present when determining the complexity of the medical decision making. For example, an encounter with a patient who presents with one stable chronic illness would amount to a low level of risk. However, if the physician actively manages prescription drug therapy during the encounter, the risk level for the visit qualifies as moderate, because prescription drug management is associated with moderate risk.

After you determine the problem points, the data points and the level of risk, you can determine the complexity of the medical decision making. The “Medical decision making” table shows how the categories work together. The highest two of three elements determine the overall level of medical decision making.

Evaluation and management (E/M) service tips and tools

Key point to remember

As stated in the Centers for Medicare & Medicaid Services (CMS) Internet-only Manuals (IOM) 100-04, Chapter 12, Section 30.6.1:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

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

1. History

2. Examination

3. Medical decision-making

When counseling and/or coordination of care dominates (more than 50%) 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.

Tips pertaining to different types of E/M services can be located by accessing the links in the table below:

CPT code range                                   Type of E/M service

99201-99205                                    Office or other outpatient E/M services for new patients

99211-99215                                    Office or other outpatient E/M services for established patients

99221-99223                                    Initial hospital care E/M services

99231-99233                                    Subsequent hospital care E/M services

96150-96152, G0425-G0427           Telehealth Services Medicare Payment for Telehealth services

Emergency CPT code billing with E & M code

E&M service with Emergency

Emergency Department Services : Claims for emergency department E&M services must be accompanied by an appropriate diagnosis code reflecting the need for the level of E&M services rendered. Inappropriate upcoding is subject to audit.

No distinction is made between new and established patients in the emergency department. Providers must use CPT-4 codes 99281 – 99285 when billing for emergency department services, whether the patient is new or established. If a recipient visits the emergency department more than once on the same date of service, the provider should use the recipient’s records from the first visit instead of completing a new evaluation. Claims for E&M services rendered more than once in the emergency department by the same provider, for the same recipient and date of service are reimbursable only if they contain medical justification or an indication from the provider that the recipient came to the emergency department more than once in the same day.

Note: Evaluation and Management (E&M) CPT-4 codes 99281 – 99285 are physician service codes and under most circumstances, only physicians may submit claims for these codes. The treating physician and the emergency department services may not submit separate claims using these codes for the same recipient and date of service.

E&M codes 99284 and 99285 are not reimbursable together or more than once to the same provider, for the same recipient and date of service. Instead, providers should use code 99283 to bill for second and subsequent recipient visits on the same date of service.


E&M: Place of Service/Facility Type Codes : The CPT-4 and HCPCS codes listed below are restricted to the following facility type/Place of Service codes:

CPT-4 Code Description- Facility TypeUB-04 -Place of Service Code CMS-1500

99201 – 99215 Office Services 13, 71, 72, 73, 74, 75, 76, 79, 83 11, 22, 24, 25, 53, 65, 71, 72

99221 – 99233, 99238, 99239 Hospital Services 11, 12 21, 25

99241 – 99245 Office Consultation 13, 14, 24, 33, 34, 44, 54, 64, 71, 72, 73, 74, 75, 76, 79, 83, 89 11, 12, 22, 23, 24, 25, 53, 55, 62, 65, 71, 81, 99

99251 – 99255 Initial Inpatient Consultation 11, 12, 25, 26, 27, 65, 71, 73, 74, 75, 76, 86 21, 31, 32, 53, 54, 99


The CPT-4 and HCPCS codes listed below are restricted to the following facility type/Place of Service codes (continued):

CPT-4 Code Description                Facility Type UB-04                     Place of Service Code CMS-1500

99281 – 99285                                 Emergency Department Services            14* 23

99291 – 99292                                 Critical Care Services                           11, 12, 13, 14* 21, 22, 23

99341 – 99350                                 Home Services                         14, 24, 33, 34, 44, 54, 64 12, 55, 99

99460, 99462                                    Newborn Care                              11, 12 21

99477                                                Neonate Intensive E&M              13, 14, 24, 34, 44, 54 or 64 21



HCPCS Code Description Facility Type UB-04 Place of Service Code CMS-1500

X9922 – X9970 Adult Subacute Care 27** 99**

X9922 – X9970 Pediatric Subacute Care 27** 99**

* Facility type “14” must be billed in conjunction with admit type “1.”

** Facility type “27” or Place of Service code “99” must be billed in conjunction with modifier HB to denote adult or HA to denote child.



Refer to the CMS-1500 Completion or UB-04 Claim Form

Completion – Outpatient section of the appropriate Part 2 manual for facility type/Place of Service codes and descriptions. Refer to the end of these sections to see the correspondence between local and national codes.

Claims for services rendered in an inappropriate facility type/Place of Service will be denied with RAD code 062, “The facility type/Place of Service is not acceptable for this procedure.”

Note: The codes listed on the previous page cannot be billed with facility type code “89” on the UB-04 or Place of Service code “81” on the CMS-1500 (independent laboratories). Claims for these codes billed with facility type code “89” or Place of Service code “81” will be denied.

CPT code 99357

CPT 99357 with E&M Services

CPT-4 Code 99357 To report prolonged inpatient E&M services, CPT-4 codes 99357 (each additional 30 minutes) must be billed in conjunction with code 99356.

Billing Calculations CPT-4 codes 99356 and 99357 are subject to the least restrictive frequency limitation as the required companion code. To calculate the amount of time that is payable for prolonged inpatient services, take the total unit/floor time and subtract the time of the primary E&M service. The following table may be used to calculate billing for prolonged inpatient E&M services.



Time of E&M visit code not included                  First hour               Each additional 30 minutes

Less than 30 minutes                                       Not reported               Not reported

30 – 74 minutes                                               99356                        Not reported

75 – 104 minutes                                             99356                        99357

105 – 134 minutes                                           99356                       99357 (quantity of 2)

135 – 164 minutes                                           99356                       99357 (quantity of 3)

165 – 194 minutes                                          99356                        99357 (quantity of 4)

Billing CPT 99355 with E & M codes

CPT 99355 with E&M services

CPT-4 Code 99355 To report additional prolonged outpatient E&M services, CPT-4 code 99355 (each additional 30 minutes) must be billed in conjunction with code 99354.

Billing Calculations CPT-4 codes 99354 and 99355 are subject to the least restrictive frequency limitation as the required companion code. To calculate the amount of time that is payable for prolonged outpatient services, take the total face-to-face time and subtract the time of the primary E&M service. The following table may be used to calculate billing for prolonged outpatient E&M services.

.

Time of E&M visit code not included              First hour            Each additional 30 minutes

Less than 30 minutes                                     Not reported                Not reported

30 – 74 minutes                                             99354                         Not reported

75 – 104 minutes                                           99354                         99355

105 – 134 minutes                                         99354                         99355 (quantity of 2)

135 – 164 minutes                                         99354                         99355 (quantity of 3)

165 – 194 minutes                                         99354                          99355 (quantity of 4)



Inpatient ServicesCPT-4 Code 99356 - To report prolonged inpatient E&M services, CPT-4 codes 99356 (inpatient setting; first hour) must be billed in conjunction with one of the following E&M service codes:



Description & CPT-4 Code


Initial hospital care and subsequent hospital care

99221 – 99223

99231 – 99233


Inpatient consultation

99251 – 99255


Nursing facility services

99304 – 99310

Inpatient psychotherapy with E&M component

90822, 90829

E & M CPT code list

E&M Services Not Separately Reimbursable

E&M Services Not Separately Reimbursable: The following CPT-4 codes for E&M services are not separately reimbursable if billed by the same provider, for the same recipient Reimbursable and same date of service. In such cases, for the following code combinations, reimbursement will be made only for the higher paying of the codes billed.

New patient, office or other outpatient visit (99201 – 99205) and another new patient, office or other outpatient visit (99201 – 99205)


Prolonged E&M Services - Prolonged services include outpatient services (CPT-4 codes 99354 and 99355) and inpatient services (CPT-4 codes 99356 and 99357). Reimbursement for these codes requires a minimum of 30 minutes face-to-face contact or unit/floor time beyond the typical time of the visit to be reported. A prolonged service of less than 30 minutes is included in the original visit and should not be reported.


Outpatient Services CPT 99354 - To report prolonged outpatient E&M services, CPT-4 codes 99354 (office or outpatient setting; first hour) must be billed in conjunction with one of the following E&M codes.

CPT-4 Code Description


Office or other outpatient visit

99201 – 99205

99212 – 99215


Office or other outpatient consultation

99241 – 99245


Domiciliary, rest home, or custodial care visit

99324 – 99328

99334 – 99337


Home Visit

99341 – 99345

99347 – 99350


Outpatient psychotherapy with E&M component

90809, 90815

Can we bill office visit when we done Lab cpt code?

Office Visits Primarily for the Purpose of HbA1c Testing

The following evaluation and management code may be billed in addition to 83036 or
83036QW for A1c testing under certain circumstances.

99211 Office or outpatient visit for the evaluation and management of an
established patient that may not require the presence of a physician.

Physician interpretation of test results is considered to be part of the evaluation and
management services provided to a patient during an office visit and is not separately
billable. However, if a patient sees a nurse or other non-physician health care professional
for the purpose of A1c testing (for example, to monitor insulin therapy) and the nurse takes
vital signs, compares the results of the A1c test to predetermined guidelines, and advises
the patient accordingly, 99211 may be billed.

Patients with abnormal results or other indications not covered by established guidelines
should always be referred to a physician. The level of office visit then reported would
depend on the evaluation and management services provided by the physician.

When a Metrika A1cNow test is provided to a patient by a physician for home testing at a
later date, the test may be submitted for payment when the patient notifies the physician of
the result and it is entered in the medical record. The date of service would be the date the
test is performed, not the date the test materials are provided to the patient. If the patient
fails to perform the test, the physician may bill the patient for the cost of the test materials;

however, the test itself can not be billed to Medicare or the patient since it was not
performed.

CPT definitions - new patient or established patient

Medical services are characterized by face – to – face services for the purposes of classifying new and established patients. 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 3 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 3 years.

The CPT definitions do not explicitly address the question of cross referral to a subspecialist within a given group. For example, if a headache specialist, whose practice is exclusively limited to the care of headache patients, practices with a group of neurologists who are not headache specialists, is it possible for a patient, who may be referred to the headache subspecialist within the same group, to be considered a new patient. The answer is yes but it would be best if the headache subspecialist had a
separate tax identification number for their subspecialty. Since the question of subspecialty reporting within a given specialty is not precisely addressed in CPT definitions, this type of cross referral would be open to interpretation.

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

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.




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

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.

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

EXAMPLE 1

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.

EXAMPLE 3

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

EXAMPLE 1

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.

EXAMPLE 2

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.

EXAMPLE 3

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:

History

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)

P) Nothing

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.

Evaluation and managment billing basic

E and M Services

When a patient is seen as a consultation or new referral, all three of the key components, History, Examination, and Medical Decision Making, must be reported and meet or exceed the stated requirements to qualify for a particular level of EM service. When an established patient (seen within the past three years) visit is reported, two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. Although time is not taken into account as a factor for determining the level of E/M care during most patient visits, the CPT codebook includes the inclusion of time as an explicit factor to assist physicians in selecting the most
appropriate level of service. The CPT codebook and the Documentation Guidelines for Evaluation and Management Services do define specific circumstances which permits time to be the sole determining factor in E/M selection. When counseling and / or coordination of care comprises more than 50% of the time spent during an encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service. This must be “face – to face” time with the patient or the family and may be unit / floor time when in the hospital. The latter includes the time in which the physician establishes and / or reviews the patient’s chart, examines the patient, writes notes, and communicates with other professionals and the patient’s family. This means that the amount of time spent in patient care is permitted to become the sole determining factor of the level of E/M service even if the physician did not perform or report any of the three key components. The physician must document the total length of time of the encounter plus a description of the counseling and / or activities involved in the coordination of care.

The record documentation must also state that more than 50% of the encounter was involved in counseling and / or coordination of care. When the physician defines that more than 50% of the visit time was dedicated to counseling and coordination of care, the E/M code can be determined by the time values that are listed in the CPT codebook for each type of E/M service and each level of care. The CPT codebook also points out that the specific times expressed in the visit code descriptors are averages, and represent a range of times that may be higher or lower depending on the actual clinical situation. In the management of headache patients, office visits are often spent in counseling and coordination of care. Physicians treating headache  patients should consider using the amount of time and effort spent performing this service as a determining factor in defining any particular office or hospital visit.


GENERAL E/M GUIDELINES

• Descriptors for the levels of E/M services recognize seven components used in defining the levels of E/M services

– History*

– Examination*

– Medical decision making*

– Counseling

– Coordination of care

– Nature of presenting problem and

– Time

*Key components Visits that consist predominately of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M services.

new patient consultation and new patient referral - what is the difference

It is also important to understand the difference between a new patient Consultation and
a New Patient Referral.

The need for a physician to request advice or expert opinion from a colleague, in the form of a professional consultation, is almost as old as medicine itself. However, physicians must be aware that there have been “clarifications” in the CPT guidelines distinguishing a Consultation (99241 – 99245), versus a New Patient Referral (99201 – 99205). For purposes of CPT, a consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and / or management of a specific problem is requested by another physician or other appropriate source. It appears there had been confusion in reporting consultative services beginning with the terms used to describe the service requested. The terms consultation and referral were mistakenly interchanged. When a physician refers a patient to another physician, it is not automatically a consultation. The revised Medicare Claims Processing Manual, effective Jan 1, 06, listed clarifications in Medicare rules in distinguishing a Consultation verses a New Patient Referral. The latter generally pays a
lower fee. Historically, physicians have known that in reporting a consultation service, the three R’s must be documented: Request, Render, and Report. Starting in 2006, CPT requirements have included one more R requirement: a Reason. There must be a request for consulting services from another physician or health care provider, the suspected or known diagnosis requires determination by a specialist who renders his / her opinion, the referring physician and consultant specifies a reason for the consultation, the treatment is undetermined or may be known, and a written report to the
requesting physician or referring source reiterating the reason for consultation plus the findings and opinions must be forwarded by the consultant. In most cases, a consultation is a one – time visit. A New Patient Referral usually has an identified problem which requires a specialist to provide care, and does not require that a written report be sent to the requesting physician or health care provider.


The policy changes or clarifications also state that a transfer of care occurs when a physician requests another doctor to assume the care of the patient. Ongoing management of the patient by the consultant physician cannot be reported using a consultation service code. Therefore, a referral for evaluation and management (E/M) cannot be considered a consultation because there has been a transfer of care. There also has been concern regarding language that the consulting physician must document the request and reason for the consultation in the patient’s medical record. Without that
documentation, the CPT code for a consultation could not be use. However, according the the E/M documentation guidelines, the consulting physician is not required to confirm that the requesting physician document his / her request. The documentation criteria for a consultation service requires that the requesting physician and consulting physician both document the request for consultation in their medical records, but each physician is required to keep their own accurate records and code accordingly. In the revised Medicare Claims Processing Manual, the section which discusses consultation followed by treatment, there are also rules governing those occasions when it may be necessary for the consulting physician to assume ongoing care of the patient. It should be
emphasized that the above guidelines differentiating a Consultation from a New Patient Referral apply primarily to Medicare patients. Currently it appears that non – Medicare payers have not yet implemented these regulations.

most frequently used evaluation managment code - office, inpatient and outpatient CPTs

The Evaluation and Management codes (99201 – 99499) are used by most physicians in
reporting a significant portion of their services and are divided into broad categories such as office visits, hospital visits, new patient encounters and consultations. Most of these categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). To properly define the E/M services, there are seven components recognized: History, Examination, Medical Decision Making (MDM), Nature of the Presenting Problem (NPP),
Counseling, Coordination of Care, and Time. The first three components, History, Examination and Medical Decision Making are recognized as the key components of E/M services. Each of the three key components is further divided into four categories. The History includes: CC, HPI, PFSH and ROS. The four levels of the Physical Examination are: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. The four elements of Medical Decision Making include: Straight

Forward, Low Complexity, Moderate Complexity and High Complexity. By year end, it is the intent for this part of the AHS website to have thoroughly reviewed the CPT (and ICD) coding system as it applies to the care of the headache patient.

To a large extent physicians use about four or five different types of service codes for the majority of care they provide. The most frequently used outpatient visit CPT codes are:

Initial visits: CPT codes 99201 - 99205
Established patient visits: CPT codes 99211 - 99215
Office consultations, new or established patients: CPT codes 99241 - 99245

The most commonly used hospital care codes are:

Initial hospital care: CPT codes 99221 - 99223
Subsequent hospital care: CPT codes 99231 - 99233
Inpatient consultations, new or established patients: CPT codes 99251 – 99255

Issues in evaluation management billing in headache

General Issues in Evaluation and Management (E&M) in Headache

By better understanding the Evaluation and Management (E/M) coding system and rules, it is the physician’s challenge to meet the demands of a complex health care system while still providing excellent patient care. While physicians are faced with multiple challenges to meet these demands, quality care of our patients is still the central theme and the reason why we became physicians. A working knowledge of the E/M methodology unites the goal of quality patient care and conformity to the Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)
regulations. A thorough understanding of the CPT coding system is essential in order to provide accurate reporting of medical services and procedures and to correctly describe medical, surgical, and diagnostic services among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. Accurate ICD codes provide The Centers for Medicare and Medicaid Services (CMS) and other third – party insurance carriers correct and complete coding to the third, fourth, or fifth digit.

In this series posted on the American Headache Society website, the CPT coding fundamentals and ICD coding recommendations for headache patients will be reviewed.New sections will be posted quarterly. This initial segment will focus on some general and important issues regarding CPT coding.
Identifying the proper CPT code exemplifies the traditional paradigm of documenting the physician’s care then trying to identify the code for the level of service provided. To help insure more accurate coding, there are some key points regarding the CPT coding system which are worth reviewing. When the AMA first developed and published the CPT nomenclature in 1966, a four – digit system was used. The second CPT edition published in 1970 presented an expanded system of terms and codes to designate diagnostic and therapeutic procedures. It was at that time that the five – digit codes
were introduced. Currently, all CPT codes are five digit codes. CPT codes are revised and updated annually by the AMA and the revisions become effective each January 1st. Since hundreds of CPT codes are added, changed, or deleted each year, it is important for all health care professionals to maintain copies of the current code books. The CPT coding system includes thousands of codes and definitions for medical services, procedures and diagnostic tests. Category 1 CPT codes describe a procedure or service identified with a five – digit numeric CPT code and descriptor nomenclature.
These codes are based on the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. Category 1 CPT codes are restricted to clinically recognized and generally accepted services, not emerging technologies, services, and procedures. All of the E/M codes are included in Category 1. Two additional CPT code categories debuted in 2002. Category 11 CPT codes are a set of optional codes developed principally to support performance measurement. These codes are intended to facilitate data collection, do
not have a relative value associated with them, and are not required for correct E/M coding. Category 11 codes have been developed for following the care and good outcomes in certain clinical conditions such as: asthma, chronic stable coronary artery disease, congestive heart failure, hypertension, osteoarthritis, prenatal care and preventive care. There are also Category 111 CPT codes which are temporary codes used for emerging technology, services and procedures. These codes may be covered by given carriers if prearranged but are not covered by Medicare.

CPT code - 99201, 99202, 99203, 99204 - 99205 - office visit code.

CPT CODE and Description

CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and 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 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and 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 of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and 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 moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and 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, 45 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.

CPT 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and 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, 60 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

Changes in the E & M code - 99201, 99202, 99203, 99204, 99205 - Update of Year 2021

AMA has revised the definitions for E/M codes 99202–99215 in the Current Procedural Terminology (CPT) 2021 codebook. The existing guidelines were developed in 1995 and 1997 and remain in effect for all other E/M services determined by history, exam, and medical decision-making (MDM).

What do the new changes mean to you? In 2021, for new and established office and other outpatient services reported with codes 99202–99215, a clinician may select the code on the basis of time or MDM.

There are three elements in MDM, and two of three are required. These elements are the number and complexity of problems addressed, amount and/or complexity of data to be reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management.

History and exam don't count toward level of service

Physicians, advanced practice registered nurses, and physician assistants won't use history or exam to select what level of code to bill for office visits 99202–99215, as they did in the past. They need only document a medically appropriate history and exam. The history may be obtained by staff members and reviewed by the billing practitioner.

While specific history and exam requirements disappear for office visit codes, they remain for all other types of visits, selected on the basis of history, exam, and MDM, such as hospital services, nursing facility services, and home and domiciliary care. So, say goodbye to "all other systems reviewed and negative" in office notes, but keep it handy for those other E/M codes.

 All time spent caring for the patient on a particular day counts

This includes all time spent on the day of service, including preparing to see the patient, seeing the patient, phone calls or other work done after the visit (if not billed with a care management or other CPT code), and documenting in the medical record. The AMA developed new guidelines for using time for office and other outpatient services. For codes 99202–99215, count all of the face-to-face and non–face-to-face time spent by the billing clinician on the day of the visit. Counseling does not need to be more than 50% of the total time

Do not include any staff time or time spent on any days before or after the visit. This allows clinicians to capture the work when a significant amount of it takes place before or after the visit with the patient, and to bill for it on the day of the visit.

According to the 2021 CPT codebook, physician or other qualified healthcare professional time includes the following activities*:

preparing to see the patient (eg, review of tests)

obtaining and/or reviewing separately obtained history

performing a medically appropriate examination and/or evaluation

counseling and educating the patient/family/caregiver

ordering medications, tests, or procedures

referring and communicating with other healthcare professionals (when not separately reported)

documenting clinical information in the electronic or other health record

independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver

care coordination (not separately reported)

*American Medical Association. CPT 2021 Professional Edition. AMA; 2020:8.

The codes now have time ranges, in place of a single threshold time.

Code Time range Code Time range

99202 15-29 minutes 99212 10-19 minutes

99203 30-44 minutes 99213 20-29 minutes

99204 45-59 minutes 99214 30-39 minutes

99205 60-74 minutes 99215 40-54 minutes

Fee schedule update on office visit CPT code (99201 - 99205)

FL Medicare Fee Schedule

CPT  2020  2021  Difference

99202  $76.34  $67.04  -12%

99203  $108.33  $103.83 -4%

99204  $166.38  $156.50 -6%

99205  $210.45   $206.77 -2%

Time Period for CPT 99201 - 99205

CPT 99201 - 10 Minute
CPT 99202 - 20 Minute
CPT 99203 - 30 Minute
CPT 99204 - 45 Munute
CPT 99205 - 60 Minute

Office Visit coding will change in 2021

• Visits will be coded based on either Time or Medical Decision-Making

• 99201 deleted

• Medically appropriate History and Examination must still be documented

• New code for prolonged services of 15-30 minutes

SELECTING CORRECT CPT CODING GUIDELINES

Select the appropriate code based on the level of service provided when you are seeing a new patient for initial evaluation of a neuromusculoskeletal condition or injury.


Documentation in the clinical record must support the level of service as coded and billed. The Key Components - History, Examination, and Medical Decision Making - must be considered in determining the appropriate code (level of service) to be assigned for a given visit.

• Select code that best represents the services furnished during the visit.

• A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer.

• Reviewers may assist with selecting codes, however, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

• Ensure that medical record documentation supports the level of service reported to a payer.

• The volume of documentation does not determine which specific level of service is billed.

• Remember - medical necessity is the overarching criteria for coverage.

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.

Time – Now and in 2021 

2020 –

 • Evaluation and Management services can be coded based on time only if visit is dominated by counseling and coordination of care – and only face-to-face time counts

• For Medicare, during Public Health Emergency, telehealth visits may be coded based on time even if not dominated by counseling and coordination of care

 2021 –

 • Office visits level will be determined either by time or by revised Medical Decision-Making criteria 

• Time is not just face-to-face time

Office visit codes - 2021 - Time - What Counts? 

• preparing to see the patient (eg, review of tests) 

• obtaining and/or reviewing separately obtained history 

• performing a medically appropriate examination and/or evaluation

• counseling and educating the patient/family/caregiver 

• ordering medications, tests, or procedures 

• referring and communicating with other health care professionals (when not separately reported) 

• documenting clinical information in the electronic or other health record • independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver • care coordination (not separately reported)


Patient Status: New or Established?

• A patient never before seen in the practice/specialty OR not seen by you or one of your partners of the same specialty in more than 3 YEARS

– E/M codes for NEW patients

• 99201, 99202, 99203, 99204, 99205
• Preventative codes – 99384, 99385, 99386, 99387
• A patient who has been seen in the office by you or one of your partners of the same specialty within the last 3 YEARS.

– E/M codes for ESTABLISHED patients

• 99211, 99212, 99213, 99214, 99215
• Preventative codes – 99394, 99395, 99396, 99397

99201: requires these 3 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.

• 99202: requires these 3 key components: An expanded problem focused history; An expanded 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 of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.

• 99203: requires these 3 key components: A detailed history; A detailed 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 moderate severity. Typically, 30 minutes are spent face-to- face with the patient and/or family. 64 

99204: requires these 3 key components: A comprehensive history; A comprehensive 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, 45 minutes are spent face-to-face with the patient and/or family.

• 99205: which requires these 3 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, 60 minutes are spent face-to-face with the patient and/or family. 




The 99201 code has more specific requirements than 99211 when it comes to elements of the history, purgative and medical decision making. In addition, 99201 is not to be used for nursing visits, as the physician needs to see the patient and establish a care plan before nurses' visits can be billed.



Established Patient


99212: requires at least 2 of these 3 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.

• 99213: requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and 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. 


99214: requires at least 2 of these 3 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.

• 99215: requires at least 2 of these 3 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-to-face with the patient and/or family. 


Evaluation and Management Services

Requirements of E&M Documentation

• 3 Components of Documentation:

– History

• Chief complaint; past medical, social, and family histories; ROS

– Exam
– Medical Decision Making

• Number of dx or tx options; amount of data; risk Subjective (patient-provided)

– Chief Complaint
– History of the present illness (HPI)
– Review of systems (ROS)
– Past, family, social history (PFSH).

Examination

– Expanded Problem-Focused – for 99202 or 99213

• a limited examination of the affected body area or organ system and any symptomatic or related body area(s) or organ system(s). Minimum 2 body areas/organ systems examined.

– Detailed – for 99203 or 99214

• an 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). Minimum 4 body areas/organ systems examined with depth in one area/system.

– Comprehensive – for 99204, 99205 or 99215

• a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s). Minimum 8 organ systems examined.

4 Types of Examination based on 1997 Guidelines:

– Problem Focused – should include performance and documentation of one to five elements identified by a bullet in one or more organ system(s) or body area(s).

– Expanded Problem-Focused – should include performance and documentation of at least six elements identified by a bullet in one or more organ system(s) or body area(s).

– Detailed – should include performance and documentation of at least twelve elements identified by a bullet in two or more organ system(s) or body area(s).

– Comprehensive – should include performance and documentation of at least eighteen elements identified by a bullet in nine or more organ system(s) or body area(s).

Time-Based Coding
99201 = 10 minutes
99202 = 20 minutes
99203 = 30 minutes
99204 = 45 minutes

99205 = 60 minutes

Can time alone be used to select an E/M code?

Answer: 
In certain circumstances, time can be used as the key or controlling factor for selecting an evaluation and management (E/M) code. When counseling and/or coordination of care dominates (e.g., more than 50 percent) the physician/patient encounter (e.g., face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), the time may be considered the key or controlling factor to qualify for a particular level of E/M service. The extent of the counseling and/or coordination of care must be documented in the medical record.

Information on E/M guidelines concerning documentation guidelines is available on the CMS Medicare Learning Network website.

Can time be used as a basis for E/M code selection in regards to add-on psychotherapy services?

Answer: 
No. Time may not be used as the basis of E/M code selection. The E/M code billed should be chosen based on the elements of the history and exam and decision making required for the complexity and intensity of the patient's condition. Additionally, prolonged services may not be reported when psychotherapy with E/M add-on codes 90833, 90836, 90838 are reported. For a listing of code definitions, please see the current CPT codebook.

If a provider sees a new patient and performs a comprehensive history, does the comprehensive history warrant submitting a higher level service?

Answer:
It depends. The level of evaluation and management (E/M) service is dependent on three key components (history, examination and medical decision making). Performance and documentation of one component (e.g., history) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.


If an established patient presents to the office for a visit with a non-physician practitioner (NPP), and during the encounter the patient has a new problem/condition, can this service be submitted 'incident to'? What if the NPP only orders tests, but does not establish a plan of care?

Answer:
No, there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment. This service must be submitted under the NPP’s NPI number. A service cannot be submitted 'incident to' even when the NPP only orders diagnostic or laboratory tests, unless the physician provides a face-to-face encounter and establishes the course of treatment (e.g., need for X-ray, apply ice, etc.) during the encounter (must be documented by the physician)

What date of service would I use for an Evaluation & Management (E/M) visit that begins on one day and ends on the next?


Response: It would be appropriate to use the date the service was completed as the date of service on the claim. The medical record must document the date of service billed. 


What is the definition of a 'new patient' when selecting an E/M CPT code?

Answer:  

'New patient' means a patient who has not received any professional services, such as an E/M service or other face-to-face service (e.g., surgical procedure), from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a three year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed), then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient, does not affect the designation of a new patient.

CPT Code 99205 OFFICE OUTPATIENT NEW 60 MINUTES

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity.

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 60 minutes face-to-face with the patient and/or family.


Requirement for CPT code 99205

Comprehensive history includes:

• Chief complaint/reason for admission
• Extended history of present illness
• Review of systems directly related to the problem(s) identified in the history of present illness
• Medically necessary review of ALL body systems’ history
• Medically necessary complete past, family and social history
• Four or more elements of the HPI or the status of at least three (3) chronic or inactive conditions, noting that medical necessity is ALWAYS the overarching criterion.

HPI – History of Present Illness: 

A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. 
Descriptions of present illness may include:
• Location
• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs/symptoms significantly related to the presenting problem(s)

Chief Complaint: The Chief Complaint is a concise statement from the patient describing:

• The symptom
• Problem
• Condition
• Diagnosis
• Physician recommended return, or other factor that is the reason for the encounter

Review of Systems: An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purpose of Review of Systems the following systems are recognized:
• Constitutional (i.e., fever, weight loss)
• Eyes
• Ears, Nose, Mouth Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary
(skin and/or breast)
• Neurologic
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

Past, Family, And/or Social History (PFSH): Consists of a review of the following:
• Past history (the patient’s past experiences with illnesses, operations, injuries and treatments) 
• Family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk)

• Social History (an age appropriate review of past and current activities)

Billing with Preventive code

A preventive E/M visit with a problem-oriented service. Use a CPT preventive medicine service code (99381-99397) plus the appropriate E/M code (99201-99215) with modifier 25 attached to show that the services were significant and separate. Link the appropriate ICD-9 code(s) to each CPT code to help distinguish the services. Note that not all payers will reimburse for both preventive and problem-oriented services on the same date

The preventive E/M visit with a problem-oriented service When a patient comes into the office for a routine preventive examination, and has significant new complaints (e.g., chest pain or irregular bleeding) and, in some instances, a new or established chronic condition (e.g., hypertension or type-II diabetes), the visit becomes a  combination of preventive and problem-oriented care. As long as the problem-oriented service is clearly documented and distinct from the documentation of the preventive service, CPT suggests submitting a preventive medicine services code (99381-99397) for the routine exam, and the appropriate office visit code (99201-99215) with modifier –25,” significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service," attached to the problem-oriented service. It's also especially important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between preventive and problem-oriented services

Centers of Medicare and Medicaid Services (CMS) in our time identify the current procedural terminology as the level one of the healthcare common procedure coding system. The cpt code 99201 denotes problem focused in the history and physical exam sections of records of new office patients.

In general, the CPT codes range from 99201 to 99499 indicates evaluation and management.  The current procedural terminology code 99201 to 99215 denotes office or other outpatient services. You have to know about these codes when you have geared up for enhancing your proficiency in the current procedural terminology day after day.

The cpt code used for indicating the level 1 new patient office visit is 99201.  As the lowest level care for every new patient in the medical office, 99201 assists all healthcare professionals and people who work in the medical sector to know about the new patient office visit directly. 

The overall health problems of these patients are minor or self-limited. The most competitive price of treatment for patients who have 99201 for new office visit nowadays attracts people who think about the cost of the initial healthcare treatment.  

There are three important elements in the documentation associated with the level 1 new patient office visit 99201. These elements are problem focused history, problem focused exam and straightforward medical decision making.  If there is current procedural terminology based on time, then patients consult with medical professionals face to face and use this appropriate documentation.

Beginners to CPT these days seek the definition of new patient. They have to keep in mind that a new patient is one who has not received any healthcare treatment from any medical professional within the past three years. An established patient is a patient who has received professional medical services from physicians in the same group within the past three years.    People who focus on the history, exam, medical decision making and typical face to face time in the new patient office visit level 1 record can get the complete details about healthcare issues of the patient. 

Q: How should the initial OB visit be reported?

A: Per ACOG guidelines, if the OB record is not initiated, then the office place of service visit should be reported separately by using the appropriate E/M CPT code (99201-99215, 99241-99245 and 99341-99350) and ICD-9-CM diagnosis code of V72.42 to be used on or before date of service September 30, 2015 or ICD-10-CM diagnosis code of Z32.01 to be used on or after date of service October 01, 2015. If the OB record is initiated during the confirmatory visit, then the confirmatory visit becomes part of the global OB package and is not reported separately.

Evaluation and Management Service Codes - General (Codes 99201 - 99499)

A. Use of CPT Codes Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management services. Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice.

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

B. Selection of Level Of Evaluation and Management Service

Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection C. Any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering UPIN/PIN.

"Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met.

CPT code 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. 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 low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.

CPT code 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. 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 severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

CPT code 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. 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 45 minutes face-to-face with the patient and/or family.

CPT code 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 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 60 minutes face-to-face with the patient and/or family.


Evaluation & management tips: Office or other outpatient services, new patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History,
2. Examination, and
3. Medical decision-making.
When billing office or other outpatient services for new patients, all three key components must be fully documented in order to bill. 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� codes and requirements

99201 - 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 (2 of 3 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

99202 - 20 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 straightforward. Documentation needed (2 of 3 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

99203 - 30 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 low complexity. Documentation needed (2 of 3 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

99204 - 45 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family and/or 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 8 or more organ system(s)
• Medical decision making that is of moderate complexity. Documentation needed (2 of 3 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

99205 - 60 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family and/or 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 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 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

Coding Question: Is it required by Medicare and Medicaid to have a referring physician in order to be able to bill for a new patient evaluation? If so, what should one do if the patient self refers himself/herself to you because of reputation/friend etc.?

Coding Response: The CMS definition for a new patient states that, “such a patient would be regarded as a new patient, a patient 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 last three years.” Therefore, any patient presenting him/herself to you would be regarded as a new patient. Effective January 1, 2010, CMS has eliminated payment for the office or other outpatient consultation codes 99241- 99245. The office and other outpatient visit codes for new patients (99201- 99205) are still recognized for reimbursement by CMS and may be used to report any new patient being seen in your practice. As a result of these changes, there is no distinction between a patient who is referred by a physician or one who is self referred; for Medicare they are both considered a new patient.  The E/M codes that can be used are CPT codes 99201 – 99205.


CPT code 99241: Office consultation for a new or established patient, which requires these 3 components:  a problem focused history, a problem focused examination, and straightforward medical decision making.

CPT code 99242: Office consultation for a new or established patient, which requires these 3 components:  an expanded problem focused history, an expanded problem focused examination, and straightforward medical decision making.

CPT code 99243: Office consultation for a new or established patient, which requires these 3 components:  a detailed history, a detailed examination, and medical decision making of low complexity.

CPT code 99244: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.

CPT code 99245: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of high complexity.


E & M code questions

Q: Will Oxford separately reimburse for the office E/M service performed with the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional? 

A: No, Oxford does not separately reimburse an E/M service in addition to the Injection service. When an E/M injection service is submitted for the same member on the same date of service, there is a presumption that the E/M service represents the physician work that is part of the Injection procedure. CPT indicates therapeutic and diagnostic injection service(s) typically require(s) direct physician supervision for any or all purposes, of patient assessment, provision of consent, safety oversight, intraservice supervision of staff, preparation and disposal of the injection materials, and the required practice training of staff for competency in the administration of Injections/Infusions. 

Example: The following example describes an E/M service that is not separately reimbursed from a therapeutic and diagnostic injection: A physician or nurse sees a patient in the office for a scheduled Injection, asks about prior allergic reactions, instructs on post-injection care of the Injection site and administers the Injection. The E/M service is integral to the Injection and is not separately reimbursable.


Q: Will Oxford separately reimburse for an office E/M service when provided in other than POS 19, 21, 22, 23, 24, 26, 51, 52, and 61 if a significant, separately identifiable E/M service is performed in addition to the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional?

A: Yes, Oxford will separately reimburse for an E/M service (other than CPT 99211) unrelated to the physician work associated with the Injection service (CPT 96372-96379) when reported with a modifier 25. Refer to Q&A #2 for a description of the physician work typically included in the allowance for the therapeutic and diagnostic Injection service. When an E/M service and an Injection or Infusion service are submitted for the same member on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service.


Example: The following example describes an E/M service that is separately identifiable from a therapeutic and diagnostic Injection: A physician evaluates a patient’s symptoms, diagnoses a serious streptococcal infection, and treats with injectable penicillin. The diagnostic process is separately identifiable from the process of the injection. The E/M service (other than CPT code 99211) should be reported with modifier 25 and is reimbursed separately from the therapeutic Injection code and the drug code for the penicillin.



BCBS Guidelines for new patient 99201 - 99203 - 99205

Medical Examinations and Evaluations with Initiation/Continuation of Diagnostic and Treatment Program:

CPT codes 92002-92014 are for medical examination and evaluation with initiation or continuation of a  diagnostic and treatment program. The intermediate services (92002, 92012) describe an evaluation of a new or existing condition complicated with a new diagnostic or management problem with initiation of a diagnostic and treatment program. They include the provision of history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated, including mydriasis for ophthalmoscopy. The comprehensive services include a general examination of the complete visual system and always include initiation of diagnostic and treatment programs. These services are valued in relationship to E/M services, though past Medicare fee schedule work relative value unit cross walks from ophthalmological services to E/M no longer exist. Nonetheless, the valuations provide some understanding of the type of medical decision-making (MDM) that might be expected. 92002 is closest to 99202 (low or moderate MDM) and 92004 is between 99203 and 99204 (moderate to high MDM).

Code 92012 is closest to 99213 (low to moderate MDM) and 92014 is closest to 99214 (moderate to high MDM).These services require that the patient needs and receives care for a condition other than refractive error.They are not for screening/preventive eye examinations, prescription of lenses or monitoring of contact lenses for refractive error correction (i.e. other than bandage lenses or keratoconus lens therapy). There must be initiation of treatment or a diagnostic plan for a comprehensive service to be reported. An intermediate service requires initiation or continuation of a diagnostic or treatment plan.  Follow-up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014. For example, care of a patient who has a history of self limited allergic conjunctivitis controlled by OTC antihistamines who is being seen primarily for a preventive exam should not be  reported using 92002-92014. A patient who has an early or incidentally identified cataract and is not being seen for visual disturbance related to the cataract, but is being seen primarily for refraction or screening, is not receiving a service reported with 92002-92014. eye examination for diabetics is considered a diagnostic treatment plan and is correctly reported with the most appropriate CPT code based upon the level of services.

Reporting screening, preventive or refractive error services with codes 92002-92014 is misrepresentation of the service, potentially to manipulate eligibility for benefits and is fraud. If the member has no coverage for a routine eye exam or lens services, it is appropriate to inform the member of their financial responsibility. Do not provide the member with a receipt for 92002-92014 if providing a non-covered preventive/screening Routine Eye Exam service as the member may seek clarification from BCBSRI and these services are typically covered.

NEW PATIENT- Same Specialty and Subspecialty:

CPT defines when a patient is new or established. It uses terms "exact same specialty" and "exact same subspecialty". CPT also states "When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialty as the physician." BCBSRI uses American Boards of Medical Specialties or American Osteopathic Association Boards to define physician specialties. In some cases BCBSRI creates additional specialties at our sole discretion. The team practice concept in the same group as defined for APRNs/PAs also could apply to other disciplines/licensure classes in reporting E/M. In general, if two or more disciplines may report E/M, it applies. For example, optometry and ophthalmology in the same group would be considered the exact same specialty/subspecialty. However, a clinical social worker and psychiatrist in the same group would not be so considered Routine Ophthalmological Evaluation, Including Refraction: HCPCS Codes S0620 and S0621 are used for these services for the new and  stablished patient, respectively.

If during the course of an evaluation it is necessary to initiate a treatment or diagnostic program, the appropriate CPT code (92002-92014) may be reported instead. An insignificant or trivial problem/abnormality that is encountered in the process of performing the routine examination and which does not require significant additional work would not warrant use of the CPT code. The HCPCSII codes, S0620-S0261, direct the claim to be correctly adjudicated based upon the member’s coverage for preventive and refraction exams. These services include screening for glaucoma or other eye disease consistent with the standards of care for a complete preventive eye examination. In the instance where a patient is treated for a condition that would allow the reporting of 92002 or 92004, but the higher level (based upon allowance) service correctly reported is the Routine Exam, S0620-S0621 may be reported. In the case where a member does not have benefits for the routine exam, as verified with BCBSRI members, the CPT should be reported and the member may be charged the difference between the charge for the non-covered routine service(s) and the charge (not allowance) for the covered service.

Refraction:

CPT 92015 describes refraction and any necessary prescription of lenses. Refraction is not separately reimbursed as part of a routine eye exam or as part of a medical examination and evaluation with treatment/diagnostic program. 


Evaluation and Management Codes

In a health department environment, a limited range of E & M codes would be submitted including 99201, 99202, 99203, 99211, 99212 and 99213. These codes are used for new patients (99201, 99202, 99203) and established patients (99211, 99212, 99213) when treated in an office and/or outpatient setting.

There also are preventive medicine codes that may be used to report the preventive medical evaluation of infants, children and adults. These visits will not have a presenting problem as they are “well” preventive visits. These codes are defined as a new or established patient and by age.


The codes for new patients are 99381-99387 and for established patients 99391- 99397. If the age of the patient does not match the age described in the code, the claim will be rejected. According to AMA CPT® and BCBSKS definitions, a new patient is a patient who hasn’t been seen for three or more years in a practice. An established patient is a patient who has been treated in the practice within the past three years. When a patient makes an appointment, a reason for the encounter needs to be established. Per AMA CPT®, a “concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient’s words.” At this point a diagnosis is established for the encounter. The reason for the encounter will be assigned an ICD-10 code to correlate with the AMA CPT® code. An ICD-10 code defines what prompted the encounter and the AMA CPT® code defines what service was performed during the encounter.

The different levels of office visits are determined by the following components:

• History

• Review of systems, personal and/or family history

• Examination

• Medical decision making

• Counseling

• Coordination of care

• Nature of presenting problem

• Time *

*In a health department setting, time probably would not be a factor in determining the level of E & M code.

However, the first four components – history, review of systems, examination, medical decision making – are key components to selecting the level of E & M
code.

The extent of the history is determined by the clinical opinion of the performing provider based on the patient’s complaints. The levels of history most likely to be seen in a health department setting are problem focused or expanded problem focused.

Per AMA CPT® guidelines they are defined as follows:

• Problem focused: chief complaint; brief history of present illness or problem.

• Expanded problem focused: chief complaint; brief history of present illness; problem pertinent system review

• Detailed: 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.

The next step is to decide on the appropriate examination level. Once again, this is determined by the performing provider. The level of examinations which  would be expected to be seen in a health department setting is as follows per CPT® guidelines:

• Problem focused: a limited examination of the affected body area or organ system.

• Expanded problem focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

• Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

The third key component is to determine the complexity of the medical decision making as determined by the performing provider. In a health department setting the two levels of medical decision making that would routinely be seen are straightforward and low complexity.

• Straightforward: minimal number of diagnoses or management options; minimal or no amount and/or complexity of data to be reviewed; minimal risk of complications and/or morbidity or mortality would be involved.

• Low complexity: limited number of diagnoses or management options; limited amount and/or complexity of data to be reviewed; low risk of complications and/or morbidity or mortality would be involved.

After selecting the level of office visit that is to be submitted for reimbursement, it needs to be determined what additional services, if any, were provided to the patient, i.e., injections and or immunizations.

The CMS HCPCS code list would be used to locate drugs to supplement the AMA CPT® codes as the second level of the coding system.

After selecting the level of office visit to be submitted, and if applicable, a second level (HCPCS) code; a diagnosis code must be assigned. Per AMA CPT®
guidelines, the primary diagnosis is what prompted the encounter as described in the patient's own words.


Per the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) guidelines, the primary diagnosis is what prompted the encounter as described in the patient’s own words


Eligible Providers For Reporting E&M Codes

Evaluation &Management were designed to classify services provided by physicians in evaluating patients and managing their medical care and these codes are drive much of revenue in physician practices as a result these codes are vulnerable under third party auditor scrutiny.

For auditing perspective, the visit notes need to satisfy the following question,
▪ Does the documentation truly justify the services rendered?
▪ Are those services medical necessary for the diagnosis treated?
▪ Whether the provider eligible to bill E&M?

E&M codes are limited only by physician and specific non-physician practitioner (NP, PA, CNS, CNM) and other qualified health care professional are excluded under statutory regulation


The below providers are eligible to bill E&M codes

1. All physicians
2. Non-Physician practitioners
a. Nurse practitioner (NP)
b. Clinical nurse specialist (CNS)
c. Certified nurse midwife (CNM)
d. Physician assistant (PA)

As per Social Security Act, Physician & NPP’s (NP, CNS, CNM, PA) alone eligible to provide Management services like preparing care plan, Treatment plan


PROPOSED PAYMENT FOR OFFICE/OUTPATIENT BASED E/M VISITS

Proposing a single PFS payment rate for E/M visit levels 2-5 (physician and non- physician in office based/outpatient setting for new and established patients).
Proposing a minimum documentation standard, for Medicare PFS payment purposes, wherein, for an office/outpatient-based E/M visit, practitioners would only need to document the information to support a level 2 E/M visit (except when using time for documentation).


MEDICAL DECISION MAKING OR TIME

CMS proposed to allow practitioners to choose, as an alternative to the current framework specified under the 1995 or 1997 guidelines, either MDM or time as a basis to determine the appropriate level of E/M visit.

This would allow different practitioners in different specialties to choose to document the factor(s) that matter most, given the nature of their clinical practice.

It would also reduce the impact Medicare may have on the standardized recording of history, exam and MDM data in medical records, since practitioners could choose to no longer document many aspects of an E/M visit that they currently document under the 1995 or 1997 guidelines for history, physical exam and MDM.


CPT CY 2018 Non-facility payment rate Proposed CY 2019 Non-facility payment rates
99201 $45 $44
99202 $76 $135
99203 $110 $135
99204 $167 $135
99205 $211 $135


CPT CY 2018 Non-facility payment rate Proposed CY 2019 Non-facility payment rates

99211 $22 $24
99212 $45 $93
99213 $74 $93
99214 $109 $93
99215 $148 $93