Use of Highest Levels of E/M Codes
To bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet the CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.
The comprehensive examination may be a complete single-system exam such as cardiac, respiratory, psychiatric or a complete multi-system examination.
CPT CODE - 99215 - Office outpatient service codes
Office Outpatient Services, 99201-99215
These codes are used when a privileged provider collects a medically related history, performs an exam, and makes a medical decision in a DoD healthcare facility on a patient who is not admitted as an inpatient to a healthcare facility.
CPT code is 99215, the Comprehensive assessment. This code requires at least two out of these three components
o A comprehensive history
o A detailed examination
o Medical decision making of high complexity
When billing code 99215, a good tip is to note that this assessment is broad in scope or content demonstrating extensive understanding of the patient’s condition. Most likely, the presenting problems are of moderate to high severity. Typically 40 minutes are spent face-to-face with the patient and/or family.
Shared Medical Appointments (SMA)
SMAs are visits when multiple patients meet with the provider and a behaviorist at the same encounter. A list of chief complaints is compiled. All patients are present for those parts of the examination not requiring privacy. The provider examines each patient individually and addresses the patient’s issues. Immediately after completing the encounter with each patient the provider documents the encounter while the behaviorist furnishes general education/counseling. When the provider completes the documentation, the provider starts the next patient’s exam. This continues until all the patients are evaluated and treated.
SMAs usually take 60-90 minutes to complete. SMAs will be coded based on documentation. Only one encounter per patient will be completed. The appropriate E&M code will be assigned according to the documentation (i.e., prevention/office visit). The modifier “TT” indicating individualized services with multiple patients present will be used
when this modifier is available for use in the ADM
Use of Highest Levels of E/M Codes
To bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet the CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.
The comprehensive examination may be a complete single-system exam such as cardiac, respiratory, psychiatric or a complete multi-system examination
CPT 99202 - 99205 or 99212 - 99215 - Review of system
Review of Systems:
These are based on questions that the provider asks the patient. At least one item must come from a specific area for that area to be included. If patient’s condition prevents them from doing a review of system (a physical or mental condition), it should be stated so and then Review of Systems will receive the necessary credit.
This generally starts with “Patient denies…” or “Patient states….”
1. Constitution – general opinion of health
2. Eyes
3. Ears, Nose, Throat, Mouth
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (and/or Breasts)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic
Statements such as “ROS done” or All ROS negative” are inappropriate.
Coding Requirements:
Level 99202, 99212 requires none
Level 99203, 99213 requires at least 1
Level 99204, 99214 requires at least 2
Level 99205, 99215 requires at least 10
procedure 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.
99202 Expanded Problem Focused 20 MIn procedure Code Descriptor Work RVU RVU RVU RVU Total RVU Total RVU 99202 Office Visit, New Pt 0.88 0.80 0.31 0.05 1.73 1.24
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