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


CPT code 99201: Office or other outpatient visit for the evaluation and management of a new patient, which 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 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.

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.


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



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.

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. 

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

No comments:

Top Medicare billing tips