CPT Code 99201, 99202, 99203, 99204, 99205 – Which code to USE

Average Fee amount


CPT Code – Description – Service Type  Average Fee schedule / reimbursement amount

99201 New patient – Problem Focused   -average fee amount –  $30 – $40
99202 New patient- Expanded Problem Focused   – average fee amount – $70 – $80
99203 New patient – Detailed   – average fee amount  $80 – $110
99204 New patient – Moderate Complexity    average fee amount $130 – $170
99205 New patient – High Complexity    –  average fee amount – $180 -$210

In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall use the CPT codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. All physicians and qualified nonphysician practitioners shall follow the E/M documentation guidelines for all E/M services.

Key components table and Requirements- See the below picture.

CPT Code 99201 OFFICE OUTPATIENT NEW 10 MINUTES 


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 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 problems are self limited or minor. Physicians typically spend 10 minutes 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.

CPT  Code 99202  OFFICE OUTPATIENT NEW 20 MINUTES

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 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 OUTPATIENT NEW 30 MINUTES 

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 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.

average fee amount-$100  – $110

CPT Code 99204 OFFICE OUTPATIENT NEW 45 MINUTES / cheat sheet

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 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.

average fee amount – $160 – $170

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.

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.

The descriptors for the levels of E&M services recognize seven components, six of which are used in defining the levels of E&M services. These components are:

1. History (key component); four recognized types of history (problem-focused, expanded problemfocused, etailed, and comprehensive)

2. Examination (key component); four recognized types of examination (problem-focused,expanded problem-focused, detailed, and comprehensive)

3. Medical decision-making (key component); four recognized types of medical decision-making (straightforward, low complexity, moderate complexity, and high complexity)

4. Counseling (contributory factor)

5. Coordination of care (contributory factor)

6. Nature of presenting problem (contributory factor)

7. Time

When selecting the appropriate level of service for an Office Evaluation and Management (E/M) CPT code, the following requirements must be satisfied and adequately documented in the clinical record:

• New Patient (CPT 99201-99204) – requires all three key components

• Established Patient (CPT 99212-99214) – requires two of the three key components

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 Definition and question

 Insurance will reimburse a new patient E/M code only when the elements of the New Patient definition have been met.

 In the instance where a physician is on-call or covering for another physician and billing under the same Federal Tax Identification number, the patient’s encounter with the on-call physician is classified as it would have been classified by the physician who was not available. This patient is not considered a new patient
merely because the visit is covered by an on-call physician from whom the patient has not previously received services.

 For the purposes of this policy, same specialty physician is defined as a physician and/or other health care professional of the same group and same specialty reporting the same Federal Tax Identification number. If a professional component of a previous procedure is billed in a 3 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

SELECTING CORRECT CPT CODE

• 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. 75


SELECTING CORRECT CPT CODE 

• 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. 76

E/M DOCUMENTATION GUIDELINES

• Two versions of the E/M Documentation guidelines approved for Medicare use –

1995 version or – 1997 version

• Either version is acceptable

• Provides may not combine parts of each to create a modified version

If a patient is seen for the first time in a practice and both a preventive visit and an Evaluation and Management (E/M) visit are provided at the same encounter, is the preventive medicine visit considered the new patient portion and the E/M visit considered established patient?

Medicare states that a patient is a new patient if the physician has not provided any professional services within the previous three years. This includes not only the individual physician but also a member of the same group with the same specialty. In the above situation, the preventive visit (whether covered or non-covered) does not preclude billing a new patient visit for the covered portion of the service as long as all requirements are met.

Definition of New Patient for Selection of E/M Visit Code

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., 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 3 years. For example, if a professional component of a previous procedure is billed in a 3 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.

NEW AND ESTABLISHED PATIENT 

Definitions of new and established patients. If a patient presents with a work related condition and meets the definition in a provider‘s practice as

• A new patient, then a new patient E/M should be billed.

• An established patient, then an established patient E/M service should be billed, even if the provider is treating a new work related condition for the first time

Is a patient new to the examiner or the same specialty in a group?
 If another physician of the same specialty in the same group had seen the patient within the last three years, then they are an established patient.


Can we bill CPT 99202 and 99381 on Same day.

No, we cant because both are E & M code and one code only eligible to pay.

We have a very large group with different tax numbers. How do we decide new patient versus established patient?


Medicare views physicians within the same group with the same specialty as the same person. A group is comprised of members having the same tax identification number. If there are different tax identification numbers, the physicians are not part of the same group for Medicare billing .

Does the three year time period for billing a new patient, go back from the date of service?
Yes, the time period is from the date of service.


 Doctor A is new to our group. If a former patient sees Doctor A under our group, is this patient new or established? If the former patient has a visit with Doctor B, in our group with the same specialty as Doctor A, is the patient new or established?

 If Doctor A sees his/her former patient, the service is an established patient visit. Doctor A’s NPI shows the provider has seen the patient within the previous three years. If the patient sees Doctor B under the new group with the same specialty without seeing the Doctor A first under the new group, then the patient is considered a new patient because the Tax ID is different.


Physician A saw the patient within the previous three years for hypertension. The patient is now coming into the office with a new problem, diabetes. Can we bill a new patient visit procedure code because this is a new problem

 No. If the patient has received professional services from the physician or a member of the same group with the same specialty in the previous three years, then you would bill any office or other outpatient services as an established patient procedure code.


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

GENERAL PRINCIPLES OF E/M DOCUMENTATION

“If it isn’t documented, it hasn’t been done” is an adage frequently heard in the health care setting.

Clear and concise medical record documentation is critical to providing patients with quality care and is required for you to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. Medical  record documentation helps physicians and other health care professionals evaluate and plan the patient’s immediate treatment and monitor the patient’s health care over time. Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

• ™ The site of service;
• ™ The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or
• ™ That services furnished were accurately reported.

General principles of medical record documentation apply to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services is appropriate:

™ The medical record should be complete and legible;
™ The documentation of each patient encounter should include:

• Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
• Assessment, clinical impression, or diagnosis;
• Medical plan of care; and
• Date and legible identity of the observer;

• ™ If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;
• ™ Past and present diagnoses should be accessible to the treating and/or consulting physician;
• ™ Appropriate health risk factors should be identified;
• ™ The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; and
• ™ The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record.
• To maintain an accurate medical record, document services during the encounter or as soon as practicable after the encounter

Reimbursement Guidelines

Please be cautious when submitting new patient CPT codes 99201 through 99205. If there has been a prior face-to-face visit by you or the same specialty within your group within the previous three year period, do not submit a new patient code. Submit the applicable established visit code instead.

There are some procedure codes that can be submitted on a claim prior to the provider seeing that patient as a new patient. These types of procedure codes tend to encompass services that are performed prior to a provider having face to face office visit.

As for all other E/M services except where specifically noted, UnitedHealthcare will not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).

UnitedHealthcare will not pay a physician for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same dateas the nursing facility admission by the same physician.

The provider must ensure that medical record documentation supports the level of service reported. The volume of documentation should not be used to determine which specific level of service is billed. In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from UnitedHealthcare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and

• Compliant with the standards of good medical practice.

The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes. UnitedHealthcare 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. UnitedHealthcare will 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.

Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV

When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier -25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).

 Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems As for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).

New patient CPT CODE as DENOMINATOR:

All patients aged 18 years and older with a diagnosis of chronic hepatitis C Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for chronic hepatitis C (ICD-10-CM): B18.2, B19.20, B19.21
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215

Modifier usage


We could use Modifier 25 with these all  CPT code 99201 -99205

Modifier -59 is not appropriate to use with weekly radiation therapy management codes (77427) or with evaluation and management services codes (99201 – 99499).

CPT Modifier 57  This modifier should not be submitted with E/M codes that are explicitly for new patients only:

This modifier 25 should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99281, 99285, 99321-99323, and 99341-99345. These codes are ‘new patient’ codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed.

However, if the new patient code and surgical procedure is a National Correct Coding Initiative (NCCI) combination, CPT modifier 25 might be required




NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.

For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnoses or as “possible,” “probable,” or “rule out” (R/O) diagnoses.

DG: The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.

DG: If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.

TIPS FOR REDUCING ERRORS

• Understand the CMS E/M documentation requirements

• Self audit

• Use the checklist included in the request for records

• Check copies for legibility and completeness

• Check for signatures – do you need to include a signature attestation or signature log?

• Were all the records pulled and submitted?

• Re-educate providers and staff when errors are identified

• Re-audit!