What E/m Codes Are Used To Report The Services Supplied By The Physician?

99201-99215: Function/Outpatient E/M Coding in 2020

Annotation: The article below was posted in 2020 and applies to coding for 2020 dates of service. For information near coding office and other outpatient E/M services in 2021, Delight come across 99202-99215: Office/Outpatient East/M Coding in 2021.

Evaluation and management (E/Thou) coding is a high-volume area of CPT^® medical coding, meaning that healthcare providers report E/Yard codes oftentimes on medical claims. The codes apply to services that a broad range of primary care and specialty providers perform on a regular basis. Some of the about unremarkably reported E/K codes are 99201-99215, which represent office or other outpatient visits.

In 2020, the E/M codes for office and outpatient visits include patient history, clinical examination, and medical controlling equally the cardinal components for determining the correct lawmaking level, and that is the version of the codes that this article focuses on. Anyone interested in Due east/Thousand coding should be aware that both the American Medical Association (AMA), which maintains the CPT^® code set, and the Centers for Medicare & Medicaid Services (CMS) have announced plans for major changes to office/outpatient E/M coding and documentation requirements in 2021. In one case those changes are implemented, much of the information below, particularly the cloth related to key components, will no longer apply to function/outpatient E/M coding.

When to Utilise New and Established Patient Due east/Thousand Codes

An important concept for proper use of office/outpatient E/M codes 99201-99215 is that CPT^® divides the codes based on whether the encounter 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) brainstorm with the same language, including a reference to a new patient: Office 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 common beginning that refers to an established patient: Office or other outpatient visit for the evaluation and management of an established patient ….

To determine whether you should cull from new patient codes 99201-99205 or established patient codes 99211-99215, you demand to know CPT^®'s definition of new and established patients for E/One thousand purposes. In short, a patient is established if the aforementioned provider, or whatever provider of the same specialty and subspecialty who belongs to the same group practise, has seen that patient for a face-to-face service within the by 36 months. Patients who don't meet that definition are new patients.

For instance, consider this example of an established patient seeing a physician in an office for an Eastward/M service. A patient saw a neurosurgeon for a face-to-face visit 26 months agone. The patient presents to the office now to see the same neurosurgeon for symptoms of lower back pain. Because the neurosurgeon provided a face-to-face service to the patient within the past 3 years, the neurosurgeon should consider this patient to be established when reporting the current E/M for lower back pain.

One final factor to consider regarding new and established patient definitions is that third-party payers may have their own 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 aforementioned specialty must bill and be paid equally though they were a single dr.," which you tin can notice in Medicare Claims Processing Manual, Chapter 12, Section xxx.6.5.

New Patient Due east/M: 3 of 3 Cardinal Components

To study an office or other outpatient visit for a new patient, you will choose from Eastward/M codes 99201-99205. As this article mentioned previously, office/outpatient visits include history, clinical examination, and medical decision-making (MDM) as the iii fundamental components for code pick. To determine which Eastward/Grand lawmaking from 99201-99205 is appropriate for a specific encounter, you must check the stated levels for the key components in each descriptor. A new patient visit must come across the levels listed for all 3 key components to authorize for a given code level.

Reviewing the sample E/M code descriptor below volition help brand those instructions about key components clearer. The areas specific to the key components are shown in bold text for emphasis.

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 test;
Medical determination making of low complexity .

Counseling and/or coordination of intendance with other physicians, other qualified health intendance 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 trouble(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

Equally you can see in a higher place, the code descriptor specifies the levels of history, exam, and MDM required for the detail code. The key component levels necessary for each code in the range vary. Table i shows the fundamental component requirements for each code from 99201-99205.

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

Lawmaking	History	Test	MDM
99201	Problem focused	Problem focused	Straightforward
99202	Expanded problem focused	Expanded problem focused	Straightforward
99203	Detailed	Detailed	Low complexity
99204	Comprehensive	Comprehensive	Moderate complexity
99205	Comprehensive	Comprehensive	High complexity

Because you must meet (or exceed) the requirements for all three fundamental components, the lowest level key component for the visit will determine which new patient E/M code is advisable. Equally an example, suppose the physician sees a new patient for an part visit. The md documents a comprehensive history and exam, and MDM of depression complexity. The history and examination levels in the case visit friction match the requirements listed for 99204 and 99205, just the lowest level key component (in this example, the low complexity MDM) determines the correct E/Chiliad code. Every bit a result, you should select 99203 for this visit considering the code meets the MDM requirement and exceeds the history and exam requirements.

Established Patient E/One thousand: 2 of 3 Key Components

You lot have just seen that a new patient Eastward/Thousand visit in the part/outpatient setting must run into the levels for all three primal components listed in a descriptor to qualify for that code. In contrast, the function/outpatient E/Thou codes for an established patient, 99212-99215, require a visit to meet simply 2 of the 3 key components listed to support the service level. Code 99211 does non reference the iii key components in its descriptor, and you will larn more about that code later on in this article.

Table two shows the primal component requirements for the different established patient office/outpatient E/M code levels.

Table 2: Key Components for Established Patient Office/Outpatient E/M Visits
(Visit must come across at to the lowest degree 2 of 3 key components in a row to qualify for the lawmaking)

Code	History	Exam	MDM
99211	(Usually, the presenting problems are minimal)
99212	Trouble focused	Trouble focused	Straightforward
99213	Expanded problem focused	Expanded problem focused	Depression complexity
99214	Detailed	Detailed	Moderate complexity
99215	Comprehensive	Comprehensive	High complexity

To understand the office of key components for an established patient visit in the outpatient setting, consider this case: A provider documents a problem focused history, expanded problem focused test, and low complexity MDM. In this case, your best choice is level-3 lawmaking 99213 (assuming added for emphasis):

99213

Function or other outpatient visit for the evaluation and direction of an established patient, which requires at least 2 of these three key components:

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

Counseling and coordination of care with other physicians, other qualified health intendance professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Commonly, the presenting problem(s) are of depression to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family unit.

Although the problem focused history meets the requirement listed for 99212, both the exam and MDM levels back up 99213. Because you need to meet the requirements for only 2 of 3 key components when selecting an established outpatient Eastward/M service, 99213 is correct.

Confirm Clinical Indications for 99211

Lawmaking 99211 differs from the other function visit codes in that information technology does non require the 3 key components. In addition, the code descriptor specifies that the visit may non require the presence of a physician or other qualified healthcare professional:

99211

Part or other outpatient visit for the evaluation and direction of an established patient, that may not require the presence of a physician or other qualified health care professional person. Usually, the presenting problem(southward) are minimal. Typically, 5 minutes are spent performing or supervising these services.

You may hear 99211 unofficially referred to as a nurse visit code because a nurse can perform the service without the billing provider nowadays in the room, and contiguous visits with physicians and nonphysician practitioners tend to meet the standards for higher level E/One thousand codes. But 99211 can apply to brief merely medically necessary visits with a dr. or a nonphysician practitioner, such as a doctor assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife.

An example of appropriate employ of 99211 may involve claret force per unit area monitoring for a hypertensive patient nether a doctor's plan of care, every bit long every bit in that location is established medical necessity for the blood pressure check.

For case, suppose a physician examines a 65-twelvemonth-sometime female patient and finds that her claret pressure is high. He decides to put her on medication to treat the problem. He notes in the chart the patient should return in 2 weeks to see the nurse for a follow-up visit that includes a claret pressure level cheque, an evaluation of how the new blood pressure medicine is working, and a review of any symptoms the patient has had since starting the new medication. In this example, documentation may support 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 take her blood pressure checked by the nurse simply because the patient wants to know the reading, the visit probably won't merit use of 99211.

Coding E/Yard Based on Fourth dimension

Selecting an office/outpatient Eastward/M code based on the key components is not the only option available. CPT^® and Medicare guidelines besides allow you to select from these E/M codes based on time.

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

To make your code choice, you need to know the intraservice time for the visit, which means face-to-face time for office and other outpatient visits. You then need to compare that time to the typical times listed in the E/G code descriptors. For example, the descriptor for 99213 states, "Typically, 15 minutes are spent face-to-face with the patient and/or family." Payer requirements may vary for whether you must meet the time listed or are allowed to circular upwards from the midway point to determine the last code selection.

Reporting Multiple Same-Day Due east/Ms

In some cases, a provider may perform more than i office or outpatient Eastward/Chiliad service for a patient on the aforementioned twenty-four hours. New patient E/M codes 99201-99205 and established patient Due east/M codes 99211-99215 don't state "per mean solar day" in their descriptors, but payer rules may prevent you lot from reporting more than one E/Yard code for a single patient on the same date of service.

For case, Medicare volition "not pay 2 E/M function visits billed by a physician (or dr. of the same specialty from the same group practise) for the aforementioned casher on the same day," according to Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.B.

In that location is an exception to Medicare'south rule about reporting multiple part and outpatient Eastward/M services on the same date, though. If the provider documents that the visits were for unrelated problems and the services could non be provided during the same encounter, then Medicare allows y'all to report split E/1000 codes for the same appointment. The example the Medicare transmission 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 distinct documentation for each service. You also will need to check payer preference for which modifier to append to the boosted Due east/1000 code, such as modifier 25 Significant, separately identifiable evaluation and management service by the same medico or other qualified health care professional on the aforementioned day of the procedure or other service or modifier 59 Distinct procedural service.

If a provider sees the patient twice on the same day for related problems, and the payer doesn't allow yous to study those services separately, and so you should combine the work performed for the ii visits, and select a single E/ Thou service code that best describes the combined service. For example, if a patient comes in with elevated claret pressure level, the physician may requite the patient medication and then have her come back later that solar day to see how she is doing. In this instance, because the visits are for the same complaint, you should combine the work performed for the 2 visits into a single E/M code.

E/M on Same Day as Small or Xxx Process

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

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

The basic idea of the global surgical package is that services unremarkably performed by a provider before, during, and subsequently a procedure are included in the surgery code instead of beingness reported separately. All those usual services go factored into the payment rate for the surgical lawmaking, so reporting those usual services separately would result in being paid twice for the same service. Payers scrutinize this expanse of coding to ensure they aren't overpaying.

Medicare'south definitions of the 0-day and 10-day global periods, bachelor in the MPFS relative value files, betoken that Medicare usually does not pay for Due east/M services during the global menstruation (assuming added for accent):

0-day global menstruation: "Endoscopic or small-scale process with related preoperative and postoperative relative values on the solar day of the procedure only included in the fee schedule payment amount; evaluation and management services on the 24-hour interval of the procedure mostly not payable."
ten-twenty-four hours global period: "Minor procedure with preoperative relative values on the mean solar day of the process and postoperative relative values during a x 24-hour interval postoperative menstruum included in the fee schedule amount; evaluation and management services on the day of the process and during the 10-day postoperative menstruum generally not payable."

One reasons E/Yard codes during the global period are "more often than not not payable" is that Medicare considers a determination to perform a minor surgery made immediately before the process to be a routine preoperative service, according to Medicare Claims Processing Manual, Chapter 12, Section 40.two.A.4. Additionally, a certain amount of history-taking and physical exam piece of work, also equally follow-up care, is expected for a minor process, so the surgical code includes payment for that work.

But the phrase "more often than not not payable" in the global period definitions leaves room for reporting Eastward/M codes separately under certain circumstances. The rule is that you may study significant, separately identifiable Due east/1000 services on the same day equally a minor procedure. Medicare provides the instance of reporting an Eastward/M code for a full neurological examination on the same date that you study a lawmaking for suturing a scalp wound for a patient with head trauma. Only you need to ensure documentation supports reporting a distinct E/Thousand service. "Billing for a visit would not be advisable if the md but identified the need for sutures and confirmed allergy and immunization status," states Medicare Claims Processing Manual, Chapter 12, Section 40.ane.C.

If documentation does support reporting an Eastward/M lawmaking on the same date as a pocket-size process code, you lot should append modifier 25 to the E/Thousand service code to acknowledge that special circumstances make the code reportable.

The National Correct Coding Initiative (NCCI) Policy Transmission for Medicare Services, Chapter 1, states that providers also may submit a distinct Due east/M code with modifier 25 on the same appointment every bit a lawmaking that has an XXX global indicator. The Xxx indicator ways the global concept does not employ to the lawmaking.

Again, for you to report the Eastward/M separately, it must be distinct from the typical pre-, intra-, and post-procedure work for the 30-global code. That means you should not report an E/1000 for the physician's supervision of someone else performing the procedure or interpretation of the effect of the procedure.

Notation that both Medicare and CPT^® country that y'all practise not need unlike diagnoses for the distinct Eastward/Thou service and the procedure. But experts advise that divide diagnoses may help show that the East/Grand was pregnant and separately identifiable from the surgery. You should not report separate diagnoses simply to improve your chances for payment, however. Ever base your ICD-ten-CM coding choices on the documentation and follow proper coding rules.

E/M Coding for Determination for Major Surgery

If a md performs an E/M service on the same date as a major procedure or on the day earlier the procedure, yous may study the Due east/M separately if the East/M resulted in the determination for surgery. Yous should append modifier 57 Conclusion for surgery to the Due east/M service code in this example.

A major procedure is 1 with a 90-day global period on the MPFS. The definition of a 90-day global menses is "Major surgery with a ane-day preoperative period and 90-mean solar day postoperative period included in the fee schedule amount."

Equally an example of proper modifier 57 employ, suppose a surgeon sees a patient with extreme hurting in the lower abdomen. The surgeon quickly determines that the patient's appendix has flare-up and schedules immediate surgery. In this instance, both the E/M service and the surgery are billable considering the E/M service resulted in the decision to perform the surgery (In other words, the surgery was not previously planned at the time of the evaluation.). You should append modifier 57 to the E/G code.

Medical Necessity Drives Due east/M Code Choice

No discussion of E/M coding would be complete without mentioning medical necessity. In all cases, whether a visit involves a new or established patient, medical necessity should determine the extent of the service provided, including elements similar the history, exam, and MDM. Consequently, medical necessity determines the concluding E/M code choice.

In the words of Medicare Claims Processing Transmission, Affiliate 12, Department 30.vi.i, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT^® code. It would not exist medically necessary or appropriate to nib a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not exist the chief influence upon which a specific level of service is billed."

Proper Use of Office/Outpatient E/M Lawmaking 99211

Evaluation and management (E/M) lawmaking 99211 is the lowest level established patient E/G code in the range for office or other outpatient visits. This level of service does not require the presence of a physician, which can lead practices to underestimate the importance of complying with reporting rules for this lawmaking. But because 99211 is an E/M lawmaking, information technology requires elements of evaluation and management to exist 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 not require the presence of a physician or other qualified health care professional person. Usually, the presenting trouble(due south) are minimal. Typically, five minutes are spent performing or supervising these services.

Support 99211 by Doing These 5 Things

When considering whether to assign 99211 for a service, recall these of import points for proper reporting.

Do brand sure there is a separate Eastward/Thousand service. Check for a documented evaluation of the patient forth with management of the patient's intendance. For case, if a nurse just refills the patient's medications and no other E/M service takes place, you should not report 99211.
Exercise ensure the patient is an established patient. Based on the CPT^® code description, you should report 99211 for an established patient , meaning 1 that has been seen past the rendering provider (or provider of same group and specialty/subspecialty) inside the past three years, in whatever setting. You cannot report 99211 for a new patient.
- The established-patient rule also is important considering Medicare applies the concept of incident-to services for 99211, pregnant a provider previously furnished a direct, personal, professional service to initiate a course of treatment, and the 99211 service being performed is an incidental part of that care plan.
Do exist sure that the supervising provider is in the function suite. Reporting 99211 to certain payers (including Medicare) requires that the supervising provider be in the office suite at the fourth dimension of the appointment. The billing provider is not required, however, to be in the room or to provide face-to-face services for the patient. The supervising provider doesn't accept to be the ane who created the care plan. Medicare Benefit Policy Manual, Chapter 15, Section sixty, provides more data well-nigh incident-to services.
Do bill the service under the supervising provider. All incident-to services must exist billed under the provider present in the office when services were performed.
Do prove that the visit is medically necessary. Look for a documented clinical reason that supports the visit and proves it was above the scope of the other services provided that twenty-four hour period. In other words, if you're reporting the E/G code along with another code, brand sure the E/M documentation is significant and separately identifiable from the procedure documentation. For example, a nurse may certificate the reason for the visit, a brief history of the patient's illness, whatever test processes such as weight or temperature, a list of the patient'due south medications, and a cursory cess to support the E/1000 in addition to the other service performed.

3 Areas to Watch to Prevent 99211 Bug

Proper reporting of 99211 as well requires you to know the top trouble spots for this code so you can avoid them. Beware of these areas:

Don't pecker 99211 for services that are function of another E/M service performed on the same solar day. For example, if your nurse measures the patient'south blood pressure and weight prior to a visit with the doc or provides counseling after the md has seen the patient, you lot should non employ 99211 because those tasks are considered function of the dr.'s office visit.
Don't report 99211 for telephone calls. There must be contiguous contact to study 99211. For example, if a nurse returns a patient'southward call and gives instructions over the phone, 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 care provider must document details including the reason for the run across, which may include educational services as well as evaluation of the patient'southward condition with management directed by the physician. Yous as well must take documentation to show 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 part, a copy of the physician'due south schedule that shows the physician was in the office at the time of the nurse visit, or a statement by the md with signature and engagement.