Where In The Cpt Manual Can You Find Clinical Examples For Reference To Coding E/m Services?

99201-99215: Office/Outpatient Due east/Grand Coding in 2020

Note: The article below was posted in 2020 and applies to coding for 2020 dates of service. For information about coding office and other outpatient E/M services in 2021, Please come across 99202-99215: Part/Outpatient E/M Coding in 2021.

Evaluation and management (E/M) coding is a high-volume area of CPT^® medical coding, pregnant that healthcare providers report E/M codes ofttimes on medical claims. The codes employ to services that a wide range of primary care and specialty providers perform on a regular basis. Some of the most ordinarily reported Due east/One thousand codes are 99201-99215, which represent office or other outpatient visits.

In 2020, the East/Chiliad codes for role and outpatient visits include patient history, clinical test, and medical controlling as the key components for determining the correct code level, and that is the version of the codes that this commodity focuses on. Anyone interested in E/M coding should be enlightened that both the American Medical Clan (AMA), which maintains the CPT^® code set up, and the Centers for Medicare & Medicaid Services (CMS) accept announced plans for major changes to function/outpatient Due east/M coding and documentation requirements in 2021. Once those changes are implemented, much of the data beneath, particularly the cloth related to central components, will no longer apply to function/outpatient Eastward/Chiliad coding.

When to Utilise New and Established Patient Eastward/M Codes

An of import concept for proper use of office/outpatient Due east/M codes 99201-99215 is that CPT^® divides the codes based on whether the see is for a new patient or an established patient.

Codes 99201-99205 apply to new patient visits. The descriptors for all 5 of the codes (99201, 99202, 99203, 99204, and 99205) begin with the same language, including a reference to a new patient: Part or other outpatient visit for the evaluation and management of a new patient ….

Similarly, the descriptors for the established-patient codes (99211, 99212, 99213, 99214, and 99215) share a mutual beginning that refers to an established patient: Office or other outpatient visit for the evaluation and management of an established patient ….

To decide whether you should cull from new patient codes 99201-99205 or established patient codes 99211-99215, y'all need to know CPT^®'s definition of new and established patients for E/M purposes. In curt, a patient is established if the aforementioned provider, or any provider of the same specialty and subspecialty who belongs to the same group exercise, has seen that patient for a contiguous service within the past 36 months. Patients who don't come across that definition are new patients.

For instance, consider this example of an established patient seeing a medico in an office for an Eastward/M service. A patient saw a neurosurgeon for a confront-to-face visit 26 months agone. The patient presents to the office at present to see the same neurosurgeon for symptoms of lower back pain. Because the neurosurgeon provided a confront-to-face up service to the patient inside the past three years, the neurosurgeon should consider this patient to be established when reporting the current E/M for lower back pain.

One terminal factor to consider regarding new and established patient definitions is that third-party payers may accept their ain rules. As an case, Medicare refers to providers of the same specialty in its definition of new and established patients, but there is no reference to subspecialty. This is in line with Medicare's rule that "physicians in the same group practice who are in the same specialty must nib and exist paid as though they were a single md," which you can observe in Medicare Claims Processing Manual, Chapter 12, Section thirty.6.five.

New Patient Due east/M: 3 of iii Primal Components

To study an function or other outpatient visit for a new patient, you will choose from Due east/M codes 99201-99205. As this commodity mentioned previously, office/outpatient visits include history, clinical test, and medical controlling (MDM) every bit the 3 key components for code selection. To decide which E/K lawmaking from 99201-99205 is appropriate for a specific meet, you must check the stated levels for the cardinal components in each descriptor. A new patient visit must come across the levels listed for all 3 key components to qualify for a given code level.

Reviewing the sample E/M code descriptor below volition aid make those instructions about key components clearer. The areas specific to the primal components are shown in assuming text for emphasis.

99203

Part or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

A detailed history;
A detailed exam;
Medical decision making of low complexity .

Counseling and/or coordination of care with other physicians, other qualified health intendance professionals, or agencies are provided consistent with the nature of the problem(southward) and the patient's and/or family unit'south needs. Usually, the presenting trouble(due south) are of moderate severity. Typically, 30 minutes are spent contiguous with the patient and/or family.

Every bit you can see in a higher place, the code descriptor specifies the levels of history, test, and MDM required for the particular lawmaking. The fundamental component levels necessary for each code in the range vary. Tabular array 1 shows the key component requirements for each lawmaking from 99201-99205.

Table 1: Key Components for New Patient Office/Outpatient East/M Visits
(Visit must meet or exceed all 3 key components in a row to authorize for the code)

Code	History	Test	MDM
99201	Problem focused	Trouble focused	Straightforward
99202	Expanded problem focused	Expanded problem focused	Straightforward
99203	Detailed	Detailed	Low complication
99204	Comprehensive	Comprehensive	Moderate complexity
99205	Comprehensive	Comprehensive	Loftier complication

Considering yous must meet (or exceed) the requirements for all 3 key components, the lowest level key component for the visit volition determine which new patient East/M code is advisable. As an instance, suppose the physician sees a new patient for an office visit. The physician documents a comprehensive history and exam, and MDM of depression complexity. The history and exam levels in the instance visit match the requirements listed for 99204 and 99205, but the everyman level key component (in this case, the low complication MDM) determines the correct Due east/M code. As a upshot, you lot should select 99203 for this visit because the code meets the MDM requirement and exceeds the history and test requirements.

Established Patient East/1000: 2 of 3 Key Components

Y'all have just seen that a new patient E/Grand visit in the office/outpatient setting must meet the levels for all three cardinal components listed in a descriptor to authorize for that code. In contrast, the office/outpatient E/M codes for an established patient, 99212-99215, require a visit to see simply ii of the 3 key components listed to support the service level. Code 99211 does not reference the 3 key components in its descriptor, and you lot will learn more than nearly that code afterwards in this commodity.

Tabular array two shows the key component requirements for the different established patient office/outpatient E/M code levels.

Table 2: Key Components for Established Patient Office/Outpatient E/Thousand Visits
(Visit must meet at least two of 3 key components in a row to authorize for the lawmaking)

Lawmaking	History	Examination	MDM
99211	(Usually, the presenting problems are minimal)
99212	Problem focused	Problem focused	Straightforward
99213	Expanded problem focused	Expanded problem focused	Low complexity
99214	Detailed	Detailed	Moderate complication
99215	Comprehensive	Comprehensive	Loftier complication

To understand the role of key components for an established patient visit in the outpatient setting, consider this instance: A provider documents a problem focused history, expanded trouble focused test, and depression complexity MDM. In this instance, your best choice is level-3 code 99213 (bold added for accent):

99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires at to the lowest degree 2 of these 3 key components:

An expanded problem focused history;
An expanded trouble focused examination;
Medical conclusion making of low complexity .

Counseling and coordination of intendance with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient'due south and/or family'south needs. Usually, the presenting trouble(s) are of low to moderate severity. Typically, 15 minutes are spent contiguous with the patient and/or family.

Although the problem focused history meets the requirement listed for 99212, both the examination and MDM levels support 99213. Because you need to meet the requirements for just 2 of 3 fundamental components when selecting an established outpatient Due east/M service, 99213 is right.

Confirm Clinical Indications for 99211

Code 99211 differs from the other office visit codes in that it does not crave the 3 key components. In addition, the code descriptor specifies that the visit may not require the presence of a physician or other qualified healthcare professional:

99211

Function 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, v minutes are spent performing or supervising these services.

Yous may hear 99211 unofficially referred to as a nurse visit code considering a nurse tin perform the service without the billing provider present in the room, and contiguous visits with physicians and nonphysician practitioners tend to meet the standards for higher level E/M codes. But 99211 can employ to brief only medically necessary visits with a physician or a nonphysician practitioner, such every bit a medico banana, nurse practitioner, clinical nurse specialist, or certified nurse midwife.

An example of advisable utilise of 99211 may involve blood force per unit area monitoring for a hypertensive patient under a physician's program of intendance, equally long as in that location is established medical necessity for the blood pressure level bank check.

For example, suppose a physician examines a 65-year-quondam female patient and finds that her blood pressure is high. He decides to put her on medication to treat the problem. He notes in the chart the patient should return in two weeks to run across the nurse for a follow-up visit that includes a blood pressure check, an evaluation of how the new claret pressure medicine is working, and a review of any symptoms the patient has had since starting the new medication. In this instance, documentation may back up reporting 99211 for the low-level visit to the nurse.

As the example emphasizes, the documentation should show clinical indications prompted the intervention to support using 99211. If a stable patient comes in to have her blood pressure checked past the nurse simply considering the patient wants to know the reading, the visit probably won't merit utilise of 99211.

Coding Due east/Thou Based on Time

Selecting an role/outpatient Eastward/M code based on the key components is non the merely option available. CPT^® and Medicare guidelines also permit you to select from these E/Chiliad codes based on time.

This arroyo to E/M coding applies only when counseling and/or coordination of care dominate the run into. The medical record must include the extent of counseling and/or coordination of care and make it clear that more than fifty% of the encounter was spent on those services.

To make your lawmaking pick, you lot need to know the intraservice time for the visit, which means contiguous time for office and other outpatient visits. You and so demand to compare that fourth dimension to the typical times listed in the E/M code descriptors. For example, the descriptor for 99213 states, "Typically, fifteen minutes are spent confront-to-face up with the patient and/or family." Payer requirements may vary for whether you must run across the time listed or are allowed to round upward from the midway point to determine the final lawmaking option.

Reporting Multiple Same-Day East/Ms

In some cases, a provider may perform more than 1 role or outpatient E/M service for a patient on the same solar day. New patient E/Thousand codes 99201-99205 and established patient E/M codes 99211-99215 don't country "per day" in their descriptors, merely payer rules may prevent you from reporting more than than one Eastward/M code for a single patient on the same date of service.

For case, Medicare will "not pay ii E/M office visits billed by a dr. (or physician of the same specialty from the same group practice) for the same casher on the aforementioned solar day," according to Medicare Claims Processing Manual, Chapter 12, Section xxx.6.vii.B.

There is an exception to Medicare's rule about reporting multiple office and outpatient E/M services on the aforementioned date, though. If the provider documents that the visits were for unrelated bug and the services could not be provided during the same see, then Medicare allows yous to report split up East/M codes for the same appointment. The case the Medicare manual provides is a patient presenting for blood pressure level medication evaluation and so returning 5 hours later for evaluation of leg pain following an blow.

To back up reporting the services separately, experts propose maintaining singled-out documentation for each service. You lot also will demand to check payer preference for which modifier to append to the additional E/M code, such as modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified wellness care professional person on the same day of the procedure or other service or modifier 59 Distinct procedural service.

If a provider sees the patient twice on the same twenty-four hour period for related bug, and the payer doesn't allow you to written report those services separately, so you should combine the work performed for the 2 visits, and select a unmarried E/ 1000 service lawmaking that best describes the combined service. For example, if a patient comes in with elevated claret pressure, the doc may requite the patient medication and so have her come back later that solar day to see how she is doing. In this case, considering the visits are for the same complaint, yous should combine the piece of work performed for the 2 visits into a single E/One thousand code.

E/Yard on Same Solar day as Minor or XXX Procedure

The rules related to reporting 99201-99215 on the same date equally a minor procedure are disruptive for many coders. You need to sympathize which services the payer considers separately reportable.

A small-scale surgical procedure is a procedure with a global period of 0 days or 10 days on the Medicare Medico Fee Schedule (MPFS). Many payers other than Medicare utilize this definition, every bit well. The global menses refers to the length of time the global surgical package applies.

The bones idea of the global surgical packet is that services usually performed by a provider before, during, and afterward a procedure are included in the surgery lawmaking instead of existence reported separately. All those usual services get factored into the payment rate for the surgical code, so reporting those usual services separately would event in being paid twice for the aforementioned service. Payers scrutinize this area of coding to ensure they aren't overpaying.

Medicare's definitions of the 0-day and 10-day global periods, available in the MPFS relative value files, indicate that Medicare ordinarily does not pay for E/M services during the global menstruation (assuming added for accent):

0-day global period: "Endoscopic or pocket-size procedure with related preoperative and postoperative relative values on the day of the process only included in the fee schedule payment corporeality; evaluation and management services on the twenty-four hours of the procedure more often than not not payable."
10-day global menstruation: "Minor procedure with preoperative relative values on the 24-hour interval of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and direction services on the day of the procedure and during the x-twenty-four hour period postoperative menses more often than not not payable."

One reasons E/M codes during the global flow are "generally non payable" is that Medicare considers a decision to perform a minor surgery fabricated immediately before the procedure to exist a routine preoperative service, according to Medicare Claims Processing Transmission, Affiliate 12, Section 40.2.A.4. Additionally, a certain amount of history-taking and physical exam work, too as follow-up care, is expected for a small-scale procedure, and so the surgical lawmaking includes payment for that work.

But the phrase "generally not payable" in the global period definitions leaves room for reporting E/M codes separately under sure circumstances. The rule is that you may report significant, separately identifiable E/G services on the aforementioned day as a pocket-size procedure. Medicare provides the case of reporting an E/M code for a full neurological examination on the aforementioned date that you written report a lawmaking for suturing a scalp wound for a patient with caput trauma. But you need to ensure documentation supports reporting a singled-out E/M service. "Billing for a visit would not be appropriate if the doc only identified the demand for sutures and confirmed allergy and immunization status," states Medicare Claims Processing Manual, Chapter 12, Department 40.i.C.

If documentation does support reporting an E/One thousand code on the same date as a minor procedure code, you should append modifier 25 to the E/Chiliad service lawmaking to acknowledge that special circumstances make the code reportable.

The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 1, states that providers as well may submit a distinct E/Grand code with modifier 25 on the same date equally a code that has an XXX global indicator. The Xxx indicator means the global concept does not use to the code.

Again, for you to report the E/M separately, it must be singled-out from the typical pre-, intra-, and post-procedure work for the XXX-global lawmaking. That means you should not written report an E/M for the physician'due south supervision of someone else performing the procedure or interpretation of the issue of the procedure.

Notation that both Medicare and CPT^® state that you practise not need unlike diagnoses for the singled-out Eastward/Thou service and the procedure. Only experts suggest that split diagnoses may help evidence that the E/One thousand was meaning and separately identifiable from the surgery. Yous should not study separate diagnoses simply to improve your chances for payment, all the same. Ever base your ICD-10-CM coding choices on the documentation and follow proper coding rules.

Eastward/M Coding for Conclusion for Major Surgery

If a physician performs an East/M service on the same date as a major process or on the twenty-four hour period before the procedure, you may report the E/M separately if the Eastward/M resulted in the decision for surgery. Yous should append modifier 57 Conclusion for surgery to the E/M service code in this example.

A major procedure is i with a xc-day global period on the MPFS. The definition of a ninety-mean solar day global catamenia is "Major surgery with a 1-day preoperative period and 90-day postoperative flow included in the fee schedule corporeality."

As an instance of proper modifier 57 apply, suppose a surgeon sees a patient with farthermost pain in the lower abdomen. The surgeon quickly determines that the patient's appendix has flare-up and schedules immediate surgery. In this case, both the E/Grand service and the surgery are billable because the East/Thousand service resulted in the decision to perform the surgery (In other words, the surgery was non previously planned at the time of the evaluation.). You should append modifier 57 to the E/M code.

Medical Necessity Drives E/M Code Choice

No give-and-take of East/M coding would exist complete without mentioning medical necessity. In all cases, whether a visit involves a new or established patient, medical necessity should decide the extent of the service provided, including elements similar the history, exam, and MDM. Consequently, medical necessity determines the final E/M lawmaking choice.

In the words of Medicare Claims Processing Manual, Chapter 12, Section 30.half-dozen.1, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT^® code. Information technology would not exist 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 chief influence upon which a specific level of service is billed."

Proper Utilize of Office/Outpatient Eastward/Thou Lawmaking 99211

Evaluation and management (Due east/M) code 99211 is the everyman level established patient E/M code in the range for office or other outpatient visits. This level of service does not require the presence of a doc, which can lead practices to underestimate the importance of complying with reporting rules for this lawmaking. But because 99211 is an Eastward/G code, it requires elements of evaluation and direction to be performed and documented.

This quick guide offers tips on the dos and don'ts of 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may non require the presence of a physician or other qualified health care professional. Unremarkably, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

Support 99211 by Doing These 5 Things

When considering whether to assign 99211 for a service, remember these important points for proper reporting.

Exercise make sure there is a carve up E/M service. Bank check for a documented evaluation of the patient along with management of the patient's care. For example, if a nurse only refills the patient's medications and no other E/1000 service takes place, you should non report 99211.
Do ensure the patient is an established patient. Based on the CPT^® lawmaking description, you should report 99211 for an established patient , pregnant 1 that has been seen by the rendering provider (or provider of same group and specialty/subspecialty) inside the by 3 years, in whatever setting. You cannot written report 99211 for a new patient.
- The established-patient rule also is important considering Medicare applies the concept of incident-to services for 99211, meaning a provider previously furnished a directly, personal, professional service to initiate a course of treatment, and the 99211 service being performed is an incidental part of that care plan.
Do be sure that the supervising provider is in the part suite. Reporting 99211 to certain payers (including Medicare) requires that the supervising provider be in the role suite at the time of the engagement. The billing provider is not required, nevertheless, to be in the room or to provide face-to-face services for the patient. The supervising provider doesn't have to be the one who created the intendance programme. Medicare Benefit Policy Manual, Chapter 15, Department 60, provides more than information about incident-to services.
Do bill the service under the supervising provider. All incident-to services must be billed under the provider nowadays in the office when services were performed.
Exercise show that the visit is medically necessary. Look for a documented clinical reason that supports the visit and proves information technology was above the telescopic of the other services provided that day. In other words, if yous're reporting the East/Yard code along with another code, brand certain the Due east/M documentation is pregnant and separately identifiable from the procedure documentation. For example, a nurse may document the reason for the visit, a brief history of the patient'due south illness, any exam processes such every bit weight or temperature, a list of the patient's medications, and a brief assessment to support the E/G in addition to the other service performed.

iii Areas to Lookout man to Prevent 99211 Issues

Proper reporting of 99211 as well requires you to know the meridian problem spots for this code so y'all can avoid them. Beware of these areas:

Don't bill 99211 for services that are part of another E/M service performed on the aforementioned day. For instance, if your nurse measures the patient'southward blood pressure and weight prior to a visit with the medico or provides counseling after the physician has seen the patient, you should non utilize 99211 considering those tasks are considered part of the physician's office visit.
Don't report 99211 for telephone calls. There must be face-to-face contact to written report 99211. For example, if a nurse returns a patient'south call and gives instructions over the telephone, you lot can't submit 99211 for reimbursement.
Don't underestimate the importance of documentation. Documentation is essential when requesting reimbursement for 99211 visits. The intendance provider must document details including the reason for the come across, which may include educational services besides as evaluation of the patient's status with management directed by the physician. You also must have documentation to evidence that the supervising provider was in the part at the time of the visit. Documentation might be a statement indicating that the nurse was working under a physician in the function, a copy of the physician'south schedule that shows the doctor was in the office at the time of the nurse visit, or a statement past the physician with signature and date.