Medicare New Edit - new patient CPT billed two times within three years

Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for a New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years

Note: This article was revised on June 4, 2013, to reflect the revised CR8165 issued on May 31. The article shows a revised list of new patient CPT codes and an added list of established patient CPT codes on page 2. Also, the CR release date, transmittal number, and the Web address for accessing CR8165 have been revised. All other information remains the same.

Provider Types Affected 

This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action Needed 

This article is based on Change Request (CR) 8165 which informs Medicare contractors about changes to Medicare's Common Working File (CWF) system that will detect erroneous billings when there are two new patient Current Procedure Terminology (CPT) codes being billed within a three year period of time by the same physician or physician group.

Make sure that your billing staffs are aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes.

The Recovery Auditors, under contract with the Centers for Medicare & Medicaid Services (CMS), are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The Recovery Auditors have identified claims with "New Patient" Evaluation and Management (E&M) services to have improper payments, because the new patient services have been billed two or more times within a 3-year period by the same physician or physician group. The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.7 provides that “Medicare 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.”

New and Established CPT code list

New and Established Patient Services 


A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient or other ambulatory facility. New patient visits are limited to one every three years, per client, per provider. 

An established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility: 

When an office visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, the office visit must be billed as an established patient visit. If a new patient visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, then the new patient visit will be denied. 

Modifier 25 may be used to identify a significant, separately identifiable E/M service performed by the same physician on the same day as another procedure or service. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client's medical record. The documentation must clearly indicate what the significant problem/abnormality was, including the important, distinct correlation with signs and symptoms to demonstrate a distinctly different problem that required additional work and must support that the requirements for the level of service billed were met or exceeded. 

The date and time of both services performed must be outlined in the medical record and the time of the second service must be different than the time of the first service, although a different diagnosis is not required. 

An established patient visit that is billed with the same date of service as a new patient visit by the same provider will be denied as part of another procedure except when the established patient visit is billed with a new THSteps medical checkup. 

Office visits (procedure codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215) provided on the same date of service as a planned procedure (minor or extensive) are included in the cost of the procedure and are not separately reimbursed. 

Office visit procedure code 99211, 99212, 99213, 99214, or 99215 must be billed by the same provider with the same date of service as a group clinical visit. 

CPT 99212, 99213 visit history

The only difference between the history requirements for a 99212 and a 99213 is the review of systems.

For a level-II visit, you need one point to meet the data requirement, which is considered minimal. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or obtaining history from someone other than the patient (e.g., a family member or caregiver). The data for a level-III visit is considered limited and requires a total of two points. You can earn two points by reviewing or ordering two different types of tests (e.g., a complete blood count and a chest X-ray). You can also earn two points by summarizing old records or discussing the case with another health care provider. 

Risk. The risk associated with an E/M visit is based on the chance that significant complications,

morbidity or mortality occur during the current encounter/procedure or between the present encounter and the next one. The guidelines characterize these in the context of the presenting problems, diagnostic procedures and management options. The highest level of risk in any one of the three categories determines the overall risk.

The risk associated with a level-II visit is considered minimal. Examples include a presenting

problem that is self-limited or minor; diagnostic procedures such as labs with venous puncture, chest X-rays, ECGs, EEGs, urinalysis, ultrasound and KOH preparation; or management options such as prescribing rest, gargles, elastic bandages and superficial dressings. Level-III visits are considered to have a low level of risk. Patient encounters that involve two or more self-limited problems, one stable

chronic illness or an acute uncomplicated illness would qualify. Diagnostic procedures with low risk include physiologic tests not under stress, non-cardiovascular imaging studies with contrast, perficial needle biopsies, labs requiring arterial puncture and skin biopsies. Lowrisk management options include prescribing over-the-counter drugs, minor surgery with no identified risk factors, physical therapy, occupational therapy and IV fluids without additives.

comparison of CPT 99212 & 99213

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.

When can we bill highest level CPT code - 99215, 99205

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

Can we choose E & M level of visit based on Time

Selection of Level of E/M Service Based on Duration of Coordination of Care and/or Counseling

Time is the key factor in selecting the level of service when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or floor time (in the case of inpatient services). In general, thephysician must complete at least two out of three criteria applicable to the type/level of service provided to bill an E/M code. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

Example:

A cancer patient has had all preliminary studies completed and a medical decision is made to implement chemotherapy. At an office visit, the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

Evaluation managment codes

Evaluation management visit with drug admin on same day

drug administration services and E/M visits billed on the same day of service as follows:

Carriers must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or non-chemotherapy drug infusion service (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 14, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). Therefore, when a medically necessary, significant, and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

Can we choose E & M level of visit based on Time

Selection of Level of E/M Service Based on Duration of Coordination

of Care and/or Counseling

Time is the key factor in selecting the level of service when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/ patient encounter or floor time (in the case of inpatient services). In general, the physician must complete at least two out of three criteria applicable to the type/level of service provided to bill an E/M code. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

Example:

A cancer patient has had all preliminary studies completed and a medical decision is made to implement chemotherapy. At an office visit, the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends on the physician service provided.

In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

When can we bill highest level CPT code - 99215, 99205

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

comparison of CPT 99212 & 99213

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.

 

E/M codes 99212-99215

•    Office visit for the evaluation and  management of an established patient

Example Scenario - 99212 - 25 20610

An established patient is seen for periodic  follow - up for hypertension and diabetes.  During the visit, the patient asked the  physician to address right knee pain which  developed after recent yard work.  The  physician performed a problem - focused  history and exam of the patient’s  hypertension and diabetes, and adjusted  medications.   Then the physician evaluated the knee and  performs an arthrocentesis.

Coding Rationale

The evaluation of the knee problem  is included in the arthrocentesis  reimbursement. The prese nting problem for the visit  was other than the knee problem.  A  separate evaluation of the  hypertension and diabetes was  performed ( Grider 4 )(and would have   been performed if the knee problem  did not exist ), making the use of  modifier 25 appropriate.

For example, the lowest level of service a physician would provide for an established patient in an Office or Other Outpatient setting (99212) requires:
 a problem focused history;
 a problem focused examination; and
 straightforward medical decision making
Average time: 10 minutes
While the highest level of service for an established patient in an Office or Other Outpatient setting (99215) requires:
 a comprehensive history;
 a comprehensive examination; and
 medical decision making of high complexity
Average time: 40 minutes
 

The clinician selects 99212 or 99215 (or any of the other levels: 99211, which is used by nonphysician ancillary staff; 99213, or; 99214) on the basis of the work required (i.e., extent of history and examination, complexity of medical decision making). The average/typical times given for each code are guidelines for the clinician and are not a requirement when using the key components (history, examination, and medical decision making) in selecting the level of service.

Q: I understand that instead of using the previous psychotherapy codes with E/M services (90805, 90807), we now must bill using the appropriate E/M code from the 99xxx series of codes (i.e., 99211, 99212, etc) and a timed add-on code for the psychotherapy. What exactly is an add-on code?

 
A: An add-on code is a code that can only be used in conjunction with another, primary code and is indicated by the plus symbol (+) in the CPT manual. The add-on code concept was developed to eliminate the redundancy of work that occurs when you provide two services on the same day (i.e., reviewing a patient’s medical record, greeting the patient). In the new Psychiatry codes there are three different types of add-on codes: 1.) Timed add-on codes to be used to indicate psychotherapy when it is done with medical evaluation and management; 2.) A code to be used when psychotherapy is done that involves interactive complexity; and 3.) A code to be used with the new crisis therapy code for each 30 minutes beyond the first hour. On the claim form, the add-on code is listed as a second code.

Q: What E/M code would I be most likely to use to replace the basic E/M services I’ve been providing to my patients with whom I do psychotherapy and evaluation and management (for which I used to code 90807)?

 
A: The most basic E/M service provided by a physician for outpatient work with an established patient is 99212. This would most likely be the appropriate code to use when you see a stable patient. There are specific guidelines for selecting E/M codes published by the Centers for Medicare and Medicaid Services, and a link can be found to these guidelines at http://psychiatry.org/cptcodingchanges. The guidelines mandate elements of history, examination, and medical decision making that must be covered to satisfy the various levels of E/M coding, and you will have to be sure that your documentation fulfills the requirements for 99212 or any other E/M code that you use. The APA has templates on its website to assist with this documentation.

Q: In my outpatient practice I often see patients for medication management and previously used CPT code 90862, which was deleted for 2013. What code will I use in place of 90862?

 
A: The typical outpatient 90862 is most similar to E/M code 99213. If the patient you are seeing is stable, and really just needs a prescription refill, code 99212 might be a more appropriate crosswalk. If you have a patient with a very complex situation, you might need to use 99214, a higher level E/M code. The E/M codes have documentation guidelines published by the Centers for Medicare and Medicaid Services (CMS) that explain how to determine which level code to choose. There is a link to this information at http://psychiatry.org/cptcodingchanges.

Q: I take no insurance in my practice, but give my patients invoices for my services, which they submit to their insurance company for reimbursement. I see my patient regularly for psychotherapy along with medical evaluation, and in the past have always coded for the visit with 90807. Under the new coding format, the patient is required to submit a bill with the new codes. I will code using 99212 (since almost all my patients are stable and just require minimal E/M) and 90836, the add-on psychotherapy code for 45 minutes of psychotherapy. My question is, with the new CPT codes, am I required to apportion my fee between these two codes? If so, is there a reasonable way to do this?

A: It has become clear that most insurers are requiring that you apportion your fee between the two codes. The most reasonable way to do this may be to base how you apportion the fee on the relative value units that Medicare assigns to each of the codes. You can find these RVUs on the APA’s website www.psychiatry.org/cptcodingchanges under the heading “RVUs.” If you take the total of the RVUs for the two codes you bill and divide that into your total fee, that will give you your practice’s fee for 1 RVU. Multiplying this by the RVUs assigned to each code will give you a fee for each code. Many payers base their fee schedules on the RVUs Medicare assigns so the provider may accept this approach.
 

If the patient’s insurer does not use the Medicare RVUs, you could get a copy of the fee schedule used by the patient’s insurer for its in-network providers. You can apply the ratio they use for the two codes to your total fee and come up with the ratio that insurer deems is appropriate for the two codes. If the insurer will not provide you with the fee schedule, ask them to provide the ratio between the relevant codes and use that information in your calculation.

99212—Two of the three following components are required:
• Problem-focused history
• Problem-focused examination
• Medical decision making that is straightforward Presenting problem(s): Self-limited or minor
Typical time: 10 minutes face-to-face with patient and/or family
99213—Two of the three following components are required:
• Expanded problem-focused history
• Expanded problem-focused examination
• Medical decision making of low complexity Presenting problem(s): Low to moderate severity
Typical time: 15 minutes face-to-face with patient and/or family

CPT 99213 billing error statistic 

CPT CODE - 99213 Established patient, moderate clinic visit.

Office or other outpatient visit for evaluation and management of an established patient.

For code 99213, the expanded assessment for office or other outpatient visit requires at least two out of these three key components to be present in the medical record:

o An expanded problem focused history

o An expanded problem focused examination

o Medical decision making of low complexity

A tip for code 99213 is to think of expanded visits as a sum of the continued symptoms or another extended form of the problem. Usually, the presenting problem or problems are of low to moderate severity. Typically 15 minutes are spent face-to-face with patient and/or family.

 A midlevel office visit is technically known as "office or other  outpatient visit for the evaluation and management of an established  patient." It is CPT code 99213.

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, detailed, 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

CPT Code 99213 (All Specialties)

Established Patient Office or Other Outpatient Visit services are a focus area for the FY 2010 Medical Review Strategy. Analysis of claims in the May 2009 sample period reveals there were 217 CERT errors. Of this number, 135 (62.21%) were for BETOS categories primarily reporting Evaluation and Management (E/M) procedure codes. Approximately 82% of the CERT errors for E/M codes were for incorrectly coded services. BETOS Category M1B - Established Patient Office or Other Outpatient Visit services had the second highest number of errors in comparison to the other E/M BETOS categories. Review of claims in the November 2009 sample period for BETOS Category M1B-Established Office Visits for the time frame of 04/01/2008 through 03/31/2009, revealed that established office visits accounted for 40% of the E/M CERT errors. Incorrectly coded services made up approximately 68% of the errors in this BETOS Category. CPT code 99213 comprised 21% of the incorrectly coded errors.

To prevent future improper payments for these services, Medical Review is utilizing both a direct and a widespread educational approach to those Part B services identified in the CERT errors. Enrollment records reveal there are approximately 90,000 providers who are able to bill for E/M services. To better identify the common billing and coding errors, Prepayment Service Specific Reviews will be utilized. Information obtained through these reviews will be utilized to further enhance and develop additional educational program

99213 - Office or other outpatient visit for the evaluation and management of an established patient, which 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.  - average fee amount - $75 - $90

In Medical billing CPT code 99213 is the most used CPT code.  Here i have given the definition and rules for when submitting with other CPT codes such as injection, surgery and vaccination and other CPT codes.

Can medical procedure codes 99393 and 99213 be billed together

Ans : Yes.

Note : A physical health (medical) provider, not a mental health provider. If you code your visit with a mental health or counseling visit you will be denied payment. You can bill medical E and M code (i.e. 99213, 99214, and 99215) using the length of the visit or the supporting elements of the visit. You must document either the length of time (and that greater than 50% of the time was spent in counseling or care coordination) or the key elements that make the diagnoses. This process also works for the way you would bill commercial health plans.

CPT codes: There are two options: (1) bill as a 99215 if you include all elements in the note. (2) bill both (a) 99393 for the health maintenance and (b) 99213 for the ADHD evaluation. A representative from Medicaid has told us they will pay in this instance. For commercial payors, you need to include the -25 modifier, but with Medicaid you do not.

ICD-9 codes: (1) V20.2 preventative care and (2) 314.0 for ADHD.

Can we use 59 modifier on CPT 81002 with 99213

Ans: We can not use.

 Solution: But we can use Mod 25 for CPT 99213.

Modifiers and Modifier Indicators for CPT 99213

The AMA CPT Manual defines modifiers that may be appended to HCPCS/CPT codes to provide additional information about the services rendered. Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. It is very important that our providers bill using the appropriate CPT/HCPCS and Modifiers. For example, when billing for separate identifiable services you must bill with the modifiers listed below in order to be eligible for reimbursement.

Modifier -25: Significant, separately identifiable Evaluation/Management by the Same Provider on the Same Date of Service of the Other Procedure or Service.

• May be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service.

• The E&M service may be related to the same or different diagnosis as the other procedure(s).

• Modifier -25 may be appended to E&M services reported with minor surgical procedures or procedures not covered by global surgery rules. Since minor surgical procedures and global procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work.

Example

Patient is an 11-month old child who is brought into the pediatrician for a routine health check. At the time of the examination, the child is found to have an acute otitis media and is given a prescription for antibiotic medication.

Incomplete Billing Complete Billing

Diagnosis V20.2 (Routine infant or child health check) 382.9 (Otitis media, acute)

V20.2 (Routine infant or child health check) 382.9 (Otitis media, acute)

Code 99213 (Office or their outpatient visit for the E&M of an established patient) 99391 (Periodic comprehensive preventive medicine, age 1 or younger)  billing CPT 99393 AND 99213 together. & 94760 with 99214
 

Medical Billing Questions

Can I bill CPT code 94760 with CPT code 99214?

Ans : No.

Note : Pulse oximetry (CPT 94760) is not allowed with any other services performed on the same day.  CPT 94760 is a status “T” code. When providing services of an E&M visit CPT 99214 and pulse oximetry CPT 94760 performed on same DOS and we cann’t (1) bill separately for each code (2) and are modifiers.

The National Correct Coding Initiative (NCCI) edits bundle the following tests when the physician performs them on the same day. Typically, to get paid for billing the codes separately, you have to use modifier -59 (Distinct procedural service). And, you can never bill pulse oximetry (such as 94760) with another payable service. To report the lab tests (85025-85027, 86001, 86003), your office must analyze the specimen, not merely send it to a lab.

Can medical procedure codes 99393 and 99213 be billed together

Ans : Yes.

Note : A physical health (medical) provider, not a mental health provider. If you code your visit with a mental health or counseling visit you will be denied payment. You can bill medical E and M code (i.e. 99213, 99214, and 99215) using the length of the visit or the supporting elements of the visit. You must document either the length of time (and that greater than 50% of the time was spent in counseling or care coordination) or the key elements that make the diagnoses. This process also works for the way you would bill commercial health plans.

CPT codes: There are two options: (1) bill as a 99215 if you include all elements in the note. (2) bill both (a) 99393 for the health maintenance and (b) 99213 for the ADHD evaluation. A representative from Medicaid has told us they will pay in this instance. For commercial payors, you need to include the -25 modifier, but with Medicaid you do not.

ICD-9 codes: (1) V20.2 preventative care and (2) 314.0 for ADHD.


 

CPT 99212, 99213 visit history

The only difference between the history requirements for a 99212 and a 99213 is the review of systems.

For a level-II visit, you need one point to meet the data requirement, which is considered minimal. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or obtaining history from someone other than the patient (e.g., a family member or caregiver). The data for a level-III visit is considered limited and requires a total of two points. You can earn two points by reviewing or ordering two different types of tests (e.g., a complete blood count and a chest X-ray). You can also earn two points by summarizing old records or discussing the case with another health care provider.

Risk. The risk associated with an E/M visit is based on the chance that significant complications,

morbidity or mortality occur during the current encounter/procedure or between the present encounter and the next one. The guidelines characterize these in the context of the presenting problems, diagnostic procedures and management options. The highest level of risk in any one of the three categories determines the overall risk.

The risk associated with a level-II visit is considered minimal. Examples include a presenting

problem that is self-limited or minor; diagnostic procedures such as labs with venous puncture, chest X-rays, ECGs, EEGs, urinalysis, ultrasound and KOH preparation; or management options such as prescribing rest, gargles, elastic bandages and superficial dressings. Level-III visits are considered to have a low level of risk. Patient encounters that involve two or more self-limited problems, one stable

CPT 99212, 99213 visit history

The only difference between the history requirements for a 99212 and a 99213 is the review of systems.

For a level-II visit, you need one point to meet the data requirement, which is considered minimal. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or obtaining history from someone other than the patient (e.g., a family member or caregiver). The data for a level-III visit is considered limited and requires a total of two points. You can earn two points by reviewing or ordering two different types of tests (e.g., a complete blood count and a chest X-ray). You can also earn two points by summarizing old records or discussing the case with another health care provider.