CPT 99212 vs 99213

There is set of Evaluation and Management Guidelines that appear every year that the provider must become aware of. There are several physicians who might be wondering whether to use coding 99212 or 99213 this will help you to go through any ecision making process that is conducted without much difficulty.

The three things that one must keep in mind for the selection of the right E/M code are:

1. History

2. Exam

3. Decision making

When you consider CPT codes 99212 to 99215 they require that only two of the three key components meet or exceed the level of code that is chosen.

The Review of Systems (ROS) is the key difference between a PF (99212) and an EPF (99213) history. The CPT 99212 does not require a ROS and documentation.

The ROS is a list of signs or symptoms a patient has had in the past, or currently may be experiencing. It is not, per se, a list of previously diagnosed diseases. Previously diagnosed diseases are considered a different portion of the history called past diseases. The ROS serves a number of different functions. If a complaint is new to the physician, the ROS are the questions asked to aid the physician in arriving at a diagnosis related to various organ systems. Often this is helpful in eliminating a diagnosis from the differential diagnosis.

All medically necessary E/M encounters performed by a physician involve at least straightforward decision-making because straightforward decision-making is the lowest level possible. That is all that is required for a CPT 99212.

The three equal elements of medical decision making are:

1. The amount of data and medical records reviewed

2. The number of diagnoses or treatment options.

3. The risk associated with  mortality or morbidity of a treatment option, diagnosis, or procedure. The highest level of risk associated with a procedure, problem, or management option determines the level of risk.

Only two of the three elements need to meet or exceed the level of decision-making which is selected.

If the level of history is counted as one of the two key components, for example a problem focused (PF) history, this is all that is required for the documentation of a CPT 99212.

You must always keep in mind the “Medical Necessity” of the visit is the highest priority for your final coding choice.