Coding Ahead

List With Office Visit CPT Codes (New & Established Patients)

The CPT codes for office visits can be found in the CPT manual; under range CPT 99202 until 99205 for office visits of new patients . For office visits of established patients, you can use range 99211 to CPT code 99215. We also included CPT 99070 in case you need to bill extra supplies/materials for office visits and CPT code 99072 if extra staff and supplies were needed during a Public Health Emergency.

CPT Code 99070

Long description of CPT 99070 : Supplies and materials [except spectacles] provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided].

Short description: Extra supplies/materials for office visit.

CPT Code 99072

Long description of CPT 99072 : Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service[s], when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

Short description: Extra supplies and staff time for office visits during Public Health Emergency.

CPT Code 99202

Long description of CPT 99202 : Office or other outpatient visit for the evaluation and management of a new patient , which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

Short description: 15-29 minute office visit for new patient evaluation and management.

CPT Code 99203

Long description of CPT 99203 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.

Short description: 30-44 minute office visit for new patient evaluation and management.

CPT Code 99204

Long description of CPT 99204 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spend on the date of the encounter.

Short description: 45-59 minute office visit for new patient evaluation and management.

CPT Code 99205

Long description of CPT 99205 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code+ selection, 60-74 minutes of total time is spent on the date of the encounter.

Short description: 60-74 minute office visit for new patient evaluation and management.

CPT Code 99211

Long description of CPT 99211 : Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional

Short description: Short office visit for established patient management.

CPT Code 99212

Long description of CPT Code 99212 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time spent on the date of the encounter.

Short description: 10-19 minute office visit for established patient management.

CPT Code 99213

Long description of CPT 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.

Short description: 20-29 minute office visit for established patient management.

CPT Code 99214

Long description of CPT 99214 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spend on the date of the encounter.

Short description: 30-39 minutes office visit for established patient management.

CPT Code 99215

Long description of CPT 99215 : Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

Short description: 40-54 minutes office visit for established patient management .

https://www.aapc.com/codes/cpt-codes-range/99211-99215/

https://www.aapc.com/codes/cpt-codes-range/99202-99205/

https://www.aapc.com/codes/cpt-codes/99070

https://www.aapc.com/codes/cpt-codes/99072

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Office/Outpatient E/M Visit Coding Changes

New guidelines, new codes.

Physicians and other practitioners who are paid under the Medicare Physician Fee Schedule (MPFS) bill for common office or other outpatient visits for evaluation and management (E/M) services using a set of Current Procedural Terminology (CPT)* codes that distinguish visits based on the level of complexity, site of service, and whether the patient is new (CPT codes 99201-99205) or established (CPT codes 99211-99215).

For the first time since it was introduced in 1992, the office/outpatient E/M CPT code set has been extensively revised, including the addition of a new code to report incremental time associated with prolonged office or other outpatient services.

Effective January 1, 2021, new reporting guidelines were implemented and code selection for office/outpatient E/M services is based on:

cpt code for return visit

Office/Outpatient E/M Codes

See the table that highlights the changes to the office/outpatient E/M code descriptors.

Reporting Guidelines

Look at the major differences in reporting guidelines for office/outpatient E/M visits.

History and Physical Examination

See how to document H&P for office/outpatient E/M services.

Take a look at the changes in time reporting requirements for office/outpatient E/M codes.

Medical Decision Making

See both the levels and elements of medical decision making.

Regulatory History and Advocacy

Take a look at the timeline and Medicare Physician Fee Schedule rulemaking process.

Frequently Asked Questions

You may have many questions about MDM, time and how to determine the level of an office/outpatient E/M visit. Find your answers here.

Our webinars show how surgeons should use office/outpatient E/M coding guidelines to properly report such services and avoid claims denials.

Contact ACS Advocacy

If you have questions about ACS Advocacy,

please contact The ACS Advocacy team.

Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines

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

CPT CODE and Description

CPT 99202 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 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. Billing Instructions: Bill 1 unit per visit.

CPT 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other 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. Billing Instructions: Bill 1 unit per visit.

CPT 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other 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. Billing Instructions: Bill 1 unit per visit.

CPT 99205 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 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. Billing Instructions: Bill 1 unit per visit.

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

Office Visit coding will change in 2021

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.

Office visit codes – 2021 – Time – What Counts? 

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. 

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.

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

Frequently asked question CPT 99205

CPT 99205 time?

Time – 50 – 64 minutes

CPT code 99205 requirements?

Key Components – Based on MDM alone (2 out of 3 elements). Elements are

  • Number and complexity of the problem
  • Amount and/or Complexity of Data to be Reviewed and Analyzed (must meet 2 of the 2 categories)
  • Risk of Complications and/or Morbidity or Mortality of Patient Management

CPT code 99205 reimbursement?

  • Non-facility – $224.25
  • Facility – $185.49

when to use CPT code 99205?

Level 5 specifies “High complexity or severity” which states

  • the risk of morbidity without treatment is high to extreme
  • the risk of mortality without treatment is moderate to high risk
  • High probability of severe, prolonged, functional impairment.

The condition may be either acute or chronic, but it must pose an immediate threat to life or bodily function.

CPT 99205 vs 99215 ?

CPT 99205 what place of service?

POS – 11 and 22

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.

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:

• Review of systems, personal and/or family history

• Examination

• Medical decision making

• Counseling

• Coordination of care

• Nature of presenting problem

*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

PROPOSED PAYMENT FOR OFFICE/OUTPATIENT BASED E/M VISITS

Proposing a single PFS payment rate for E/M visit levels 2-5 (physician and non- physician in office based/outpatient setting for new and established patients). Proposing a minimum documentation standard, for Medicare PFS payment purposes, wherein, for an office/outpatient-based E/M visit, practitioners would only need to document the information to support a level 2 E/M visit (except when using time for documentation).

MEDICAL DECISION MAKING OR TIME

CMS proposed to allow practitioners to choose, as an alternative to the current framework specified under the 1995 or 1997 guidelines, either MDM or time as a basis to determine the appropriate level of E/M visit.

This would allow different practitioners in different specialties to choose to document the factor(s) that matter most, given the nature of their clinical practice.

It would also reduce the impact Medicare may have on the standardized recording of history, exam and MDM data in medical records, since practitioners could choose to no longer document many aspects of an E/M visit that they currently document under the 1995 or 1997 guidelines for history, physical exam and MDM.

CPT CY 2018 Non-facility payment rate Proposed CY 2019 Non-facility payment rates 99201 $45 $44 99202 $76 $135 99203 $110 $135 99204 $167 $135 99205 $211 $135

CPT CY 2018 Non-facility payment rate Proposed CY 2019 Non-facility payment rates

99211 $22 $24 99212 $45 $93 99213 $74 $93 99214 $109 $93 99215 $148 $93 

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A mental health billing service, cpt code 99202: billing guide & reimbursement rates [2024].

In our guide to CPT Code 99202, we’ll teach you about this straightforward complexity evaluation and management procedure code, 99202 guidelines for billing, and the CPT Code 92202 reimbursement rate for Medicare in 2024.

cpt code 99202

If you’re struggling with billing or coding, consider reaching out to our mental health billing service at TheraThink for help.  If you love billing, please read on!

CPT Code 99202 Definition

cpt code 99202 reimbursement rate

99202 Description:  Office or other outpatient visit for the evaluation and management of a new patient which requires a medically appropriate history and/or examination and straightforward medication decision making.

CPT Code 99202 Reimbursement Rate (Medicare, 2024): $71.06

In the past years, this E/m code has been paid $73.97 by Medicare in 2021. ( Source )

CPT Code 99202 Time Length:  15-29 Minutes

cpt code 99202 description

An average session length for an initial 99202 evaluation and management session is around 20 minutes.

( Source ) ( Source ) ( Source )

99202 Billing Guidelines:

Using CPT code 99202 requires a medical decision making level of straightforward with a medically appropriate history or examination.

“In 2021, new patient codes 99202-99205 no longer require the three key components or reference typical face-to-face time. Instead, each service includes “a medically appropriate history and/or examination,” and code selection is based on the MDM [medical decision making] level or total time spent on that date.”

This decision was made on 1/1/2021 to update the descriptor for Group 1 CPT and HCPCS codes 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215.

Pick the code that is based on the length of service and complexity of medical decision making and appropriate level of care required.

99202 Requirements:

  • Medical decision making: straightforward
  • Time length: 15-29 minutes
  • Evaluation of clinical history and examinations

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Documenting Patient Return Visits and Following Up on Missed Appointments

  • December 1, 2018
  • CAP Risk Management Department

As every patient visit concludes with a documented office visit encounter, the visit note should include when the patient is advised to return. The suggested return visit (i.e. f/u in 2 weeks, 1 month) should be documented in the Action or Plan portion of the progress notes and the patient instructed to make a follow-up appointment before leaving the office. At the end of each visit, the physician should confirm that the patient understands the rationale for the recommended return visit or treatments, the presumptive diagnosis, next steps for follow up, and signs or symptoms to watch for.

Following up with a patient is important and should be tailored to the patient’s symptoms and the progression of the disease. Following up gives the practitioner an opportunity to address unresolved concerns, respond to symptoms that have worsened or have not improved with treatment, or formulate a differential diagnosis through appropriate testing. Clinical conditions can be difficult to diagnose during a single patient encounter. There may not be enough time to address multiple problems during a visit. Providing return visits and following up may potentially identify a serious unsuspected medical condition.

Continuity of care can be compromised when more than one provider is involved in a patient’s care. This underlines the importance of clear communication between providers and across settings. A patient injury resulting from the patient’s own failure to return for a follow-up appointment could help defend against a claim of negligence or delay in treatment or diagnosis. When no specific follow-up is required, a “return if any problems” (specific problems can be noted if needed) or just f/u PRN in the note means the doctor gave the patient the responsibility to decide when to return.

Going a step further, the office should have a system in place to follow-up on patients that do not schedule their next appointment before leaving the office such as a simple tickler file that reminds staff to call the patient in the next day or two to schedule the next patient visit.

Staff also should document no-shows and/or canceled appointments in the medical record of patients who consistently miss or frequently cancel appointments. It is a good practice to develop a system to notify the provider of these instances so the provider can decide whether a follow-up phone call to reschedule should be made.

Many factors can contribute to non-adherence such as communication issues, a patient’s level of comfort with their treatment plan, or their ability to afford a treatment. It may take an additional effort on your part to address unresolved health complaints by non-adherent patients to address serious conditions.

Having this information documented in the patient medical record will show the provider is managing the patient's care and will undoubtedly help forego unnecessary medical liability claims. Careful history-taking and documentation are crucial.

Learn more about how the Cooperative of American Physicians, Inc. (CAP) can support your practice by downloading our free guide The Physician's Action Guide to Reducing Risk and Improving Business , which includes resources and tips to help physicians and medical staff solve common practice problems associated with seemingly routine tasks

This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.

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Clear the Confusion about New Patient CPT Code Range

Defining ‘new patient’.

According to the CPT definition, a new patient is someone who has not received professional services from the physician or another physician in the same specialty and group practice within the last three years, while an established patient has received such services within the last three years. Differentiating between new & established patients and accurate use of new patient CPT codes is important for reimbursement purposes. Understanding the terms ‘professional services’ and ‘group practice’ is crucial in making this differentiation. As a primary care physician, it can be challenging to incorporate this definition into your coding habits, but this article will explain why it matters and will also share the new patient CPT code range.

New Patient CPT Code Range 99202 – 99205

The new patient CPT code range is used to describe the initial visit with a healthcare provider. These codes were last revised in the year 2021 by the AMA to better reflect the level of complexity and time required for a visit. The new patient CPT code range is as follows:

CPT Code 99202

This code describes a level 2 new patient visit that requires a low level of medical decision-making. The typical time for this visit is 20 minutes. Documentation requirements for new patient CPT code 99202 are as follows:

  • History: Expanded problem-focused history
  • Exam: Expanded problem-focused exam
  • Medical decision-making: Straightforward complexity
  • Typical face-to-face time: 15-29 minutes

CPT Code 99203

This code describes a level 3 new patient visit that requires a moderate level of medical decision-making. The typical time for this visit is 30 minutes. Documentation requirements for new patient CPT code 99203 are as follows:

  • History: Detailed history
  • Exam: Detailed exam
  • Medical decision-making: Low complexity
  • Typical face-to-face time: 30-44 minutes

CPT Code 99204

This code describes a level 4 new patient visit that requires a high level of medical decision-making. The typical time for this visit is 45 minutes. Documentation requirements for new patient CPT code 99204 are as follows:

  • History: Comprehensive history
  • Exam: Comprehensive exam
  • Medical decision-making: Moderate complexity
  • Typical face-to-face time: 45-59 minutes

CPT Code 99205

This code describes a level 5 new patient visit that requires a comprehensive level of medical decision-making. The typical time for this visit is 60 minutes. Documentation requirements for new patient CPT code 99205 are as follows:

  • Medical decision-making: High complexity
  • Typical face-to-face time: 60-74 minutes

It’s important to note that CPT code selection is not just based on the typical face-to-face time alone, but also on the level of history, exam, and medical decision-making documented in the medical record. The typical face-to-face times listed here are just guidelines and should not be the sole factor in determining the accurate code from the new patient CPT code range.

The time listed for each code is an average and can vary based on the complexity of the patient’s medical history, the number of complaints or symptoms, and other factors. Providers should use their clinical judgment to determine the appropriate code based on the level of medical decision-making required.

New Patient vs. Established Patient

Previously, distinguishing between new and established patients was simple. A new patient was someone who had not been seen before or did not have a current medical record. However, due to changes in healthcare delivery, this differentiation has become more complicated.

As mentioned above, a new patient is someone who has not received professional services from the physician or another physician in the same specialty and group practice within the last three years, while an established patient has received such services within the last three years.

Another important distinction between the new patient and established patient codes is that the new patient code range (99202-99205) mandates all three key components (history, examination, and medical decision-making) to be met, whereas the established patient code range (99211-99215) requires only two of the three key components to be met.

Since the requirements for coding problem-oriented new patient visits are more rigorous, there may be instances where the same service components would result in an established patient code with more RVUs than the appropriate new patient code.

Defining ‘Professional Services’ and ‘Group Practice’

Defining ‘professional services’.

‘Professional Services’ refer to those medical services that are provided by a physician or qualified healthcare provider in person and reported by a specific CPT code. The key phrases are ‘face-to-face’ and ‘reported by a specific CPT code(s).’

This definition is important because it helps practices to determine whether a patient is new or established, based on whether the physician or provider has provided a face-to-face service to that patient within the last three years.

If the physician or provider has not provided a face-to-face service to the patient within the last three years, then the patient is considered a new patient and can be billed using the appropriate code from the new patient CPT code range.

Defining ‘Group Practice’

‘Group Practice’ refers to a healthcare organization or facility where multiple healthcare providers work together, such as a medical group or clinic. In group practices, the definition of a ‘new patient’ can be more complex than in solo practices because the patient may have seen another provider within the same group.

The critical element in this scenario is the specialty designation of the healthcare provider. Suppose a patient has been receiving care from a pediatrician within your practice regularly. If the patient reaches the age of 18 and decides to transfer care to a family physician within the same practice, they would be considered a new patient.

How does new patient CPT code range impact your practice?

The new patient CPT code range aims to more accurately reflect the complexity of the visit and the amount of time required to complete it. This can have an impact on your practice in several ways.

  • First, the new codes may require you to adjust your documentation practices to ensure that you are accurately capturing the level of medical decision-making required for a visit. This may include updating your electronic health record (EHR) templates or training staff on the new codes and documentation requirements.
  • Second, the new codes may impact reimbursement rates for new patient visits. Insurance companies may adjust their reimbursement rates based on the level of complexity of the visit, which could result in higher or lower reimbursement rates for your practice.
  • Finally, the new codes may impact patient satisfaction and retention. Patients may be more likely to return to a provider who takes the time to thoroughly assess their medical history and develop a comprehensive treatment plan. By accurately capturing the complexity of the visit with the new CPT codes, you can demonstrate to patients that you are providing high-quality care.

In conclusion, the new patient CPT code range is an important update for primary care providers. By accurately reflecting the level of complexity and time required for the initial visit, these codes can help providers better document their services, improve reimbursement rates, and enhance patient satisfaction and retention. As a primary care provider, it’s important to stay up-to-date on coding changes to ensure that your practice is providing high-quality care and maximizing revenue opportunities.

In case you find it difficult to accurately use the new patient CPT code, we can assist you. Medical Billers and Coders (MBC) is a leading revenue cycle management company providing complete medical billing and coding services.

We can assist you in the accurate selection of CPT codes as per the insurance company’s guidelines. We take complete ownership for accurate claim submissions for all major insurance companies like Medicare, Medicaid, and commercial insurance companies in your area.

Our expertise in primary care billing ensures maximum insurance reimbursements while following compliance with regulatory requirements.

To know more about our primary care billing services, email us at: [email protected] or call us at: 888-357-3226 .

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Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits

Tyler j. miksanek.

1 Biological Sciences Division, Pritzker School of Medicine, University of Chicago, Chicago, Illinois

Samuel T. Edwards

2 Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland

3 Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon

George Weyer

4 Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, Illinois

Neda Laiteerapong

Accepted for Publication: July 17, 2022.

Published: August 31, 2022. doi:10.1001/jamanetworkopen.2022.29504

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Miksanek TJ et al. JAMA Network Open .

Author Contributions : Drs Laiteerapong and Miksanek had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Miksanek, Laiteerapong.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Miksanek.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Miksanek, Laiteerapong.

Obtained funding: Miksanek.

Administrative, technical, or material support: Miksanek, Laiteerapong.

Supervision: Edwards, Weyer, Laiteerapong.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by an internal grant from the John D. Arnold, MD Scientific Research Prize through the Pritzker School of Medicine (Dr Miksanek).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Associated Data

This economic evaluation estimates annual revenue for different durations of patient encounters among physicians in outpatient clinics.

How does the 2021 change in evaluation and management services guidelines, which allow for time-based billing inclusive of work before and after outpatient visits, affect reimbursement of physicians?

In this economic evaluation of patient visits of different lengths, the medical decision-making billing method was associated with higher reimbursement for return patient visits lasting 10 or 15 minutes. For longer visits, the time-based billing method was associated with higher reimbursement.

Findings of this study suggest that the time-based billing is associated with economic benefits for physicians in lower-volume clinics with longer patient visits.

Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing.

To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths.

Design, Setting, and Participants

This economic evaluation used 2019 billing data for outpatient E/M codes and 2021 reimbursement rates from the Centers for Medicare & Medicaid Services. Modeling of generic clinic templates was performed to estimate expected yearly E/M revenues for a single full-time physician working in an outpatient clinic using fee-for-service billing.

Main Outcomes and Measures

Yearly E/M revenues for different patient visit templates were modeled. The standardized length of return patient visits was 10 to 45 minutes, and new patient visits were twice as long in duration.

Under MDM-based billing, increased visit length was associated with decreased E/M revenue ($564 188 for 30-minute new patient visit/15-minute return patient visit vs $423 137 for 40-minute new patient visit/20-minute return patient visit). Under time-based billing, yearly E/M revenue remained similar across increasing visit lengths ($400 432 for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Compared with time-based billing, MDM-based billing was associated with higher E/M revenue for 10- to 15-minute return patient visits ($400 432 vs $564 188). Time-based billing was associated with higher E/M revenue for return patient visits lasting 20 minutes or longer. The highest modeled E/M revenue of $846 273 occurred for 10-minute return patient visits under MDM-based billing.

Conclusions and Relevance

Results of this study showed that the relative economic benefits of MDM-based billing and time-based billing differed and were associated with the length of patient visits. Physicians with longer patient visits were more likely to experience revenue increases from using time-based billing than physicians with shorter patient visits.

Introduction

In the US, physicians still receive most of their reimbursement for outpatient visits through the fee-for-service model. 1 Within the fee-for-service model, evaluation and management (E/M) services guidelines have been used for decades to establish the level at which physicians can bill patient encounters. 2 Under this system, a Current Procedural Terminology ( CPT ) code can be selected to ascertain reimbursement for a given encounter according to medical decision-making (MDM) levels. 3 Levels of MDM, in turn, are based on the number and complexity of problems addressed at the encounter. 4 However, studies show that physicians spend substantial time doing work that is not explicitly reportable by the E/M system of MDM-based billing, including medical record review, documentation, and coordination of care. 5 , 6 As a result, many physicians report averaging 1 to 2 hours of unreimbursed, after-hours work daily. 6 , 7 , 8 After-hours work is especially common for primary care physicians (PCPs) and has frequently been associated with increased rates of burnout. 9 , 10 , 11

In addition to MDM-based billing, physicians can bill on the basis of visit length. Historically, time-based billing has counted only time spent face-to-face with patients. 4 However, substantial changes to time-based billing occurred in the 2021 E/M guidelines. The 2021 guidelines allow physicians to bill for face-to-face time and for previously unreimbursed time spent on medical record review, documentation, and coordination of care on the day of the patient encounter. 3 , 12 Because time-based billing monetizes previously unreimbursed services, it offers physicians an opportunity to increase revenue, compared with MDM-based billing, which still does not reimburse for these services. However, variations in patient panels and clinic schedules may be factors in different lengths of an average patient visit. 13 , 14 In turn, individual physicians are likely to see different outcomes associated with these changes in billing. Changes to the economic incentives for different visit lengths could have downstream implications for clinic scheduling and patient access.

In this study, we aimed to compare E/M reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths. Specifically, to identify the economic incentives of expanded time-based billing for E/M revenue in different practices, we performed modeling of the expected E/M revenue for a single physician working in a primary care clinic. We then performed sensitivity analyses to illustrate how these billing changes altered the incentives for specialty physicians as well. We hypothesized that physicians with longer encounters would benefit the most from time-based billing.

The University of Chicago Institutional Review Board deemed this economic evaluation to be nonhuman participant research and thus exempt from approval and the requirement for informed consent. We followed the Consolidated Health Economic Evaluation Reporting Standards ( CHEERS ) reporting guideline.

The modeling of yearly E/M revenues for an individual full-time physician compared MDM-based billing revenue with time-based billing revenue. We defined full-time work as 8 hours a day of seeing patients for 220 days a year. We limited the analysis to new and return outpatient visits with CPT codes 99202 to 99215, which represent the codes physicians can use for time-based billing. 4 To calculate the proportion of new and return visits seen by PCPs, we used 2018 National Ambulatory Medical Care Survey (NAMCS) summary data. 15 We then assumed that the physician in the model matched the proportions from the NAMCS data, with 8.5% new patient visits and 91.5% return patient visits. 15 We also assumed that the physician scheduled twice as much time to see new patients as return patients. These assumptions allowed us to construct yearly schedules for physicians to see patients at different time intervals.

The shortest patient visit template gave physicians 20-minute visits with new patients and 10-minute visits with return patients. We analyzed schedules at regular-length visits until the longest duration, which gave physicians 90 minutes for new patient visits and 45 minutes for return patient visits. From these schedules, we calculated the number of new and return patient visits that a physician seeing patients at each time interval would have per year. Although physicians can specify MDM-based billing or time-based billing for individual patients, the physician in the model used the same billing modality for all visits to enable a comparison of the maximal incentives offered by each billing method.

MDM-Based Billing

To calculate MDM-based billing revenue, we used Centers for Medicare & Medicaid Services (CMS) data to estimate the proportion of outpatient visits with CPT codes 99201 to 99215 before the addition of time-based billing. 16 Although time-based billing was not added until 2021, we used 2019 CMS billing data to avoid any possible short-term implications of the COVID-19 pandemic. 17 The use of 2019 CMS billing data also ensured that any billing changes associated with the expansion of time-based billing did not alter the MDM-billing distribution. 18

We used CPT codes 99201 to 99215 billed to CMS in 2019 by family medicine and internal medicine practitioners (representing approximately 73 million visits) to calculate the percentage of encounters billed at each E/M level under MDM-based billing. We assumed that the PCP in the model would match this billing distribution. By multiplying the number of new and return patient visits by the proportion of visits billed at each rate, we estimated the yearly number of visits billed at each E/M level. We then multiplied this yearly number by the 2021 CMS national nonfacility price reimbursement rate for each of the CPT codes (99201-99215) to arrive at the total yearly revenue ( Figure 1 ). 19

An external file that holds a picture, illustration, etc.
Object name is jamanetwopen-e2229504-g001.jpg

MDM indicates medical decision-making.

The CPT code 99201 for level 1 new patient visits was retired between 2019 (when the billing data we used were collected) and 2021 (when time-based billing was expanded). 4 The code represented less than 0.4% of new patient visits and was used for new patient visits that could not meet level 2 billing criteria. 4 , 16 Because the code no longer exists, we assigned it a value of $0, limiting the analysis to CPT codes 99202 to 99215.

Statistical Analysis

Time-based billing.

We assigned CPT codes to each visit according to the length of the encounter, including qualifying non–face-to-face time such as preparing for and documenting the encounter, as outlined in the 2021 E/M services guidelines. 4 The 2018 NAMCS data were used to identify the breakdown of new and return patient visits. As with MDM-based billing, with time-based billing, the 2021 CMS nonfacility price reimbursement value was assigned to each CPT code. By multiplying the reimbursement for each visit by the number of total visits scheduled for the year, we calculated total yearly revenue.

Conversion Factor

Time-based billing, but not MDM-based billing, allows physicians to receive reimbursement for the non–face-to-face tasks that consume a substantial portion of the clinic day. 5 Many physicians also spend varying lengths of time performing these tasks before or after clinic. 6 , 7 , 8

To standardize these differences, the model constrained the physician’s clinic day to a total of 8 hours of both patient-facing and non–face-to-face tasks. Within this 8-hour day, we assumed a physician using time-based billing consistently performed reimbursable work. However, a physician using MDM-based billing who was performing the same work would have time that was not reimbursed. To account for this discrepancy, we conducted a literature review to estimate the percentage of a physician’s day spent on tasks reimbursed under time-based billing but not under MDM-based billing. We found evidence that, on average, physicians spend approximately 3 minutes before each patient visit and 4.5 minutes after each patient visit, for a total of 7.5 minutes per visit on tasks that are not reimbursed under MDM-based billing. 7 , 20 , 21 Data from NAMCS showed that a PCP spends a mean (SD) 20.9 (0.4) minutes of face-to-face time with each patient, suggesting a total of 28.4 minutes per patient. 15 From these calculations, we assumed that only 74% (20.9 minutes divided by 28.4 minutes) of a physician’s time under MDM-based billing was reimbursable. Thus, we multiplied all revenues from MDM-based billing by a conversion factor of 0.74.

Sensitivity Analysis

The base-case analysis ( Table 1 ) assumed that the physician in the model matched the billing rates from family medicine and internal medicine practitioners in the CMS data set. To extend the analysis to other specialties, we ran sensitivity analyses examining the implications of specialty-specific E/M billing distributions for the model. We chose dermatology as a representative specialty that, on average, billed at a much lower E/M level than primary care. Cardiology was selected as a representative medical specialty that tended to bill at higher E/M levels than primary care. 16

Abbreviations: CPT , Current Procedural Terminology ; MDM, medical decision-making.

In addition, we used NAMCS data to calculate the relative proportions of new and return patients seen by specialists, who had a higher fraction of new patient visits than PCPs (23% vs 9%). 15 We performed a sensitivity analysis adjusting the value of the conversion factor used to account for work not reimbursed under MDM-based billing given that past studies have found physicians spend different lengths of time on unreimbursed tasks. 20 , 21 , 22 We also reran the base-case scenario using facility price reimbursement values. All statistical calculations and plots were performed with Excel (Microsoft Corp).

The yearly E/M revenue in the model varied inversely with the length of patient visits for MDM-based billing ( Figure 2 ). The shortest patient visit (20-minute new patient visits, and 10-minute return patient visits) was associated with the highest E/M revenue ($846 273) ( Table 2 ). Yearly E/M revenue decreased with each successive increase in patient visit length ($564 188 for 30-minute new patient visit/15-minute return patient visit vs $423 137 for 40-minute new patient visit/20-minute return patient visit), with the longest visits (90-minute new patient visits, and 45-minute return patient visits) showing the lowest E/M revenue ($188 065).

An external file that holds a picture, illustration, etc.
Object name is jamanetwopen-e2229504-g002.jpg

New visits are assumed to always be twice as long as return visits. MDM indicates medical decision-making.

Abbreviation: MDM, medical decision-making.

Unlike with MDM-based billing, the E/M revenue in the model remained relatively similar across visit lengths ($400 432 for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Similar to MDM-based billing, the highest E/M revenue ($567 649) was associated with 20-minute new patient visits and 10-minute return patient visits. The lowest E/M revenue ($385 614) was associated with 50-minute new patient visits and 25-minute return patient visits ( Table 2 ).

In the model, the revenue advantage of time-based billing over MDM-based billing increased with longer visits. For shorter visits (20-30 minutes for new patient visits, and 10-15 minutes for return patient visits), MDM-based billing was associated with higher revenues compared with time-based billing (20-minute new patient visits and 10-minute return patient visits: $846 273 vs $567 649). Starting at 40-minute new patient visits and 20-minute return patient visits, time-based billing, compared with MDM-based billing, was associated with higher E/M revenues ($458 718 vs $423 137).

We found that MDM-based billing revenue was sensitive to the E/M billing distribution used. Substituting cardiology’s billing distribution of higher mean E/M levels compared with primary care was associated with a 15% increase in all E/M revenues for MDM-based billing across visit lengths (eg, from $423 137 to $486 024 for 40-minute new patient visits and 20-minute return patient visits) ( Table 2 ). This shift played a role in time-based billing compared with MDM-based billing maximizing E/M revenue only when new patient visits were 60 minutes or longer and when return patient visits were 30 minutes or longer. In contrast, using dermatology’s lower E/M billing distribution was associated with a 32% decrease in all E/M revenues for MDM-based billing across visit lengths (from $423 137 to $287 849 for 40-minute new patient visits and 20-minute return patient visits). This shift played a role in time-based billing compared with MDM-based billing having greater E/M revenue starting at 30-minute new patient visits and 15-minute return patient visits. Table 2 shows that MDM-based revenue results were sensitive to the conversion factor used to account for unreimbursed work in MDM-based billing. We found that MDM-based revenue increased by 36% across visit lengths when the conversion factor was increased to 1 (from $423 137 to $574 980 for 40-minute new patient visits and 20-minute return patient visits), and MDM-based revenue decreased by 12% when the conversion factor was decreased to 0.65 (from $423 137 to $373 737 for 40-minute new patient visits and 20-minute return patient visits). Increasing the percentage of new patient visits to the 23% new patient rate of specialty physicians affected all E/M revenue calculations by less than 10% ( Table 2 ). For this higher proportion of new patient visits, time-based billing was associated with more revenue than MDM-based billing starting at 40-minute new patient visits and 20-minute return patient visits ($418 978 vs $387 757). Using facility price reimbursement levels was associated with lowered E/M revenues globally without affecting the previously noted association between MDM-based billing and time-based billing (eTable in the Supplement ).

A variety of factors were associated with the length of patient visits, but any clinic must consider economic incentives to maintain its financial viability. The underlying hypothesis that physicians change their billing practices in response to shifting billing incentives is already supported by data, such as a recent study reporting that physicians began billing at higher levels just after the expansion of time-based billing. 18 In the present economic evaluation, the models suggested that E/M revenue from MDM-based billing was associated with the number of patients seen per hour, incentivizing shorter patient visits. Conversely, we found that time-based billing removed the association between patients seen per hour and revenue, allowing physicians to have longer patient visits without a loss of E/M revenue. In this modeling, shorter visit lengths were associated with MDM-based billing that earned more revenue, although we acknowledge that physicians are unlikely to bill higher levels of MDM with extremely short visits. As clinic visits became longer, time-based billing became the revenue-maximizing strategy. Moreover, MDM-based billing and time-based billing yielded the most similar revenues in the model for 40-minute new patient visits and 20-minute return patient visits. This visit length in the model was associated with reported mean visit lengths in actual practice, suggesting that time-based billing has limited implications for many clinics. 15 , 18 , 23

The highest E/M revenues in this study were associated with a combination of short patient visits and MDM-based billing. This finding demonstrates that time-based billing is unlikely to change financial incentives given for shorter visits. 24 , 25 However, physicians with lower volume and longer patient visits can benefit from time-based billing in multiple ways. Because the models showed E/M revenue was greater with time-based billing at longer visits, physicians with longer patient visits were more likely to gain a revenue increase from the time-based billing option than physicians who scheduled shorter patient visits. In addition, because there was no association between E/M revenue and visit length under time-based billing, physicians with longer patient visits could further extend their patient visit length without a noticeable decrease in E/M revenue. Previous studies have shown that physicians with time constraints are less likely to complete preventive medicine tasks. 26 , 27 Therefore, the flexibility in patient scheduling afforded by time-based billing could help physicians better address preventive medicine. 28 A decrease in patients per hour could also be used to help physicians complete non–face-to-face tasks, such as documentation, that traditionally have been pushed to after hours, potentially contributing to decreased physician burnout. 29 , 30 At the national level, longer patient visits with a fixed health care workforce could be a factor in limited patient access to their physicians. Moreover, by reimbursing only physician time, time-based billing may penalize efficient physicians and team-based clinic workflows and reward inefficiencies while increasing health care costs.

High-volume and low-volume clinics are often located in different areas and serve different patient populations. 8 , 9 As such, the finding that time-based billing is less advantageous for high-volume clinics than low-volume clinics could have implications for health equity. As a corollary, high-volume, low-acuity specialties may be less likely to benefit from time-based billing. 31

Downstream sources of revenue and the health care system within which a clinic operates were factors in a clinic’s scheduling, suggesting that E/M revenue does not exist in a vacuum. Similarly, individual physicians affiliated with a large health care system may react more directly to economic incentives affecting their personal earnings, not the clinic’s overall revenue. 32 Still, previous studies have found that clinics respond to economic incentives. 14 , 18 , 32 , 33 More research is needed to better understand the complex economic associations between outpatient scheduling and billing incentives.

Strengths and Limitations

This study has some strengths. The findings are generalizable to different specialties and clinics. The study reported yearly E/M revenue for a full-time physician, but the relative difference between MDM-based billing revenue and time-based billing revenue was unchanged for physicians not working a 40-hour work week. By incorporating data on after-hours documentation, we also accounted for the much longer work hours actually spent by many physicians who are scheduled to be in clinic for 40 hours a week. 6 , 7 , 8 Although the base-case scenario used PCP billing data, the analysis can be readily repeated for specialty or even clinic-specific data. For example, we used previously published work to estimate the mean time spent on unreimbursed tasks per patient, but physicians can substitute individual data to obtain a personalized estimate.

This study also has some key limitations. First, we used Medicare data to identify the distribution of CPT codes for MDM-based billing. If Medicare beneficiaries required more MDM than patients without Medicare coverage, then use of Medicare data artificially increased the MDM-based billing revenues. We also were unable to account for the implications of recent changes to simplify MDM-billing guidelines because the MDM billing distribution in the model used 2019 data.

Second, we assumed that physicians used either MDM-based billing or time-based billing for all of their patient encounters. In actual practice, a physician can choose whichever billing method can generate a higher reimbursement. 4 Similarly, in the model, the calculations held constant the E/M billing distribution for MDM across different lengths of visits. In practice, short patient visits are more likely to be coded at lower E/M levels, potentially contributing to MDM-based revenue being artificially high at shorter visits. Furthermore, longer visits are more likely to be coded at higher E/M levels, which could be associated with MDM-based revenue calculations being lower for longer visits.

Third, the E/M revenue model excluded services other than patient visits with CPT codes 99201 to 99215 and thus did not consider other sources of revenue, such as preventive health visits or procedures. The model also did not consider downstream revenue associated with ancillary services (eg, laboratory testing and diagnostic imaging) or referrals made during visits. The financial value of these services and referrals can be much greater than the E/M revenue associated with direct patient visits. 34 Downstream revenue is likely to vary greatly between specialties and even practices within a specialty but regardless serves as an economic argument against longer patient visits. Even if time-based billing allows a physician to not lose direct E/M revenue with longer patient visits, fewer visits may ultimately be a factor in decreased downstream revenue. For example, PCPs affiliated with a large health care system generate referrals to that system’s specialists, providing a source of revenue that goes well beyond the individual physician. Under advanced alternative payment models, such as global capitation, revenue is disconnected from billing regardless of visit length. 35 , 36 , 37 Physicians using these reimbursement systems are unaffected by time-based billing. 38

Conclusions

In this economic evaluation, we reported yearly E/M revenue earned exclusively through MDM-based billing or time-based billing for an individual physician receiving 2021 CMS nonfacility price reimbursement rates. The economic benefits of MDM-based billing and time-based billing were associated with the length of patient visits. Using time-based billing, physicians with longer patient visits were more likely to experience revenue increases than physicians with shorter patient encounters. Possible future changes to billing regulations may have similar implications for physicians’ economic incentives. Further studies using clinic- or system-level data may clarify the association of indirect and downstream revenue with the economic incentives offered by time-based billing.

Supplement.

eTable. E/M Revenue Calculated with Facility Price Payments

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Gerrit Cole injury update: Yankees ace to miss 10-12 weeks with elbow issue, could avoid surgery, per reports

The reigning cy young winner was not recovering well between starts this spring.

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New York Yankees ace and reigning AL Cy Young winner Gerrit Cole is expected to miss 10-12 weeks due to an elbow injury, MLB.com reported on Thursday . Cole had an MRI, CT scan, and X-rays, but there was enough concern with the testing that Dr. Neal ElAttrache requested an in-person appointment in Los Angeles on Thursday. 

Following the visit, the New York Post reported that Cole's visit with the renowned surgeon brought relatively good news. The report indicates there's a belief that Cole can avoid Tommy John surgery and he could return after "rest, rehab and some conservative, non-surgical" treatment. 

Boone had previously said Cole was not recovering well between outings, which was the cause for concern, initially. Cole threw two innings and 39 pitches in his spring debut on March 1. He has not appeared in a game since, but he did throw 45-50 pitches in a simulated game on March 7.

It goes without saying that losing Cole for any length of time would be a devastating blow to a Yankees team that is trying to return to the postseason after going 82-80 in 2023, the franchise's worst record in three decades. He is one of the most indispensable players in the game not only because of his excellence, but also his durability. Cole last missed a start for a non-COVID reason in 2016.

The Yankees traded four pitchers, including Michael King and depth starters Jhony Brito and Randy Vásquez , for Juan Soto over the winter. As things stand, their rotation depth chart looks like this:

  • RHP Gerrit Cole (possibly out two months)
  • LHP Carlos Rodón (injured and ineffective in 2023)
  • RHP Marcus Stroman
  • LHP Nestor Cortes (injured and ineffective in 2023)
  • RHP Clarke Schmidt (set new career high by 66 innings in 2023)
  • RHP Luke Weaver
  • RHP Will Warren (not on 40-man roster)

A long-term injury to Cole could push the Yankees into the market for a starting pitcher . Reigning NL Cy Young winner Blake Snell and former Yankee Jordan Montgomery remain unsigned free agents, and either would be a significant upgrade to New York's rotation, with or without Cole. Whether the Yankees engage Scott Boras, who also represents Cole, on Montgomery or Snell remains to be seen.

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Cole, 33, can opt out of the remaining four years and $144 million remaining on his contract after the season , though the Yankees can void the opt out by exercising a one-year club option worth $36 million. Obviously a major elbow injury could affect that decision, though that is still a ways away.

Last season, Cole led the league in innings (209), ERA (2.63), ERA+ (165), WHIP (0.98), and WAR (7.4), among other things. He missed approximately six weeks spread across two injured list stints with elbow inflammation while with the Pittsburgh Pirates in 2016. That is the only other arm injury of his career.

Unfortunately for the Yankees, Cole is not their only star player undergoing testing this week. Outfielder Aaron Judge underwent an MRI on his abs and is taking some time off before swinging a bat again .

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Peach State CB Planning Return After Strong Clemson Visit

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A coveted Peach State defensive back was impressed with his first experience at Clemson.

Three-star cornerback Kaleb Lanier visited for the Elite Junior Day and it’s a visit that he’s been excited about for months.

Lanier’s connection with the Tigers dates back to an in-school visit from cornerbacks coach Mike Reed at Decatur High School. From then, he eyed this first visit at Clemson and got to experience what the program has to offer

“It was a really, really nice visit, I learned a lot about the program got a chance to check out the practice. See some guys that I know personally,” Lanier told The Clemson Insider.

The Peach State cornerback has connections with Tigers cornerbacks Shelton Lewis and Myles Oliver. All three hail from Georgia and the relationship stems from it.

Lanier had the opportunity to see practice, including watching Lewis on the field. Watching Reed in practice was another moment to see the program up close and meeting afterwards, he was given extra encouragement from the Clemson coaches.

“Coach Reed told me that he wanted me to visit again, you know, not just once, but go back up there and experience it more. Get acclimated with the environment more and Coach Swinney afterwards, he’s telling me keep working,, told me I’m on my way, and just stay with it,” Lanier said.

Football plays a heavy factor in Lanier’s recruitment and that’s a given, but the off-field opportunities the Tigers present interests him. He said that the program feels like “one big family” and it shows no one becomes disconnected. Seeing Trevor Lawrence arrive at practice was an example of it that stood out to Lanier

“The on-field success, national championships, ACC championships, bowl wins, but what really stands out is how much coach Swinney prioritizes education. His number one priority is making sure that you get a degree and that you have something to fall back on once your playing days are over. They take building you as a man off the field very seriously with their PAW program. Just how dedicated coaches to making you become a better an really sticks out,” Lanier said.

While Lanier doesn’t currently hold an offer from Clemson, he said the program still stands “pretty high” at this point in time. He’s planning on making another visit “soon” whether it be for the spring game in April or the Dabo Swinney Camp in June.

Photo courtesy of Kalen Lanier(@KalebLanier) on X

2025 recruiting class , Clemson Tigers football recruiting , Kaleb Lanier , Mike Reed , Football , Recruiting

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BREAKING: Residents in suburban Philadelphia township told to shelter in place after 'confirmed shootings'

This group brings free coding education to low-income NYC students

Tucked away in the red-brick community center of the South Jamaica Houses in New York City is a small multipurpose room filled with plastic chairs and tables. A piece of paper taped on the door shows the schedule for the day, with Hood Code starting at 3 p.m.

Right on time, the quiet room fills with giggles and sneaker squeaks as children pile into the space, each one excitedly talking over the other.

Hood Code is an organization that provides free coding classes to students who live in New York City’s public housing. These apartments are home to more than half a million low-income families and individuals, and 25% of them are under the age of 18.

Founder Jason Gibson said Hood Code was specifically designed to be in these neighborhoods and serve this community.

“I wanted to make it easily accessible to the families that live here,” Gibson said.

Jason Gibson in front of Brooklyn Bridge.

The workshops introduce the basics of coding to kids ages 8 to 13, and have so far taught about 300 children in housing buildings throughout the city. The programming also helps them develop problem-solving skills, self-confidence and innovative thinking.

The students primarily use Scratch , a free block-based language program that allows them to express themselves creatively and learn the basics of how professional coders create some of their favorite video games and apps.

Many of the kids embark on quests to make their own video games or re-create their favorites, finding inspiration in games like Flappy Bird and Geometry Dash.

Gibson founded Hood Code in 2019, but the idea for the program was born two years prior — from behind bars.

While serving a five-year sentence, Gibson spent most of his time expanding his knowledge and researching both the tech industry and African American history.

“That was my first opportunity to really sit down and read,” Gibson said. “And I realized how much of a disadvantage I was at and how kids from my neighborhood are in.”

Those disadvantages inspired Gibson to provide his community with opportunities that he says he wished he had growing up.

Jason Gibson, back left, stands with Hood Code students as they receive their participation certificate.

“I think my life could have possibly been different,” Gibson said. “I’ve always been an entrepreneur, I’ve always had that spirit. I could have been maybe one of the big tech founders.”

Gibson used that entrepreneurial spirit to gather sponsors and community members to ensure that Hood Code would be free for students and a paid job for tutors, many of whom are in high school.

“Coding is not always necessarily accessible to kids that we teach,” Chigo Ogbonna said. She’s a high school senior and a tutor at Hood Code. She and her friend Sara Outar decided to take on the job together.

“I think it’s because we both come from low-income communities, we understand. I didn’t have a computer until basically high school, when I had to do online school. And I didn’t even know that jobs in coding existed,” Outar said.

Black people made up 9% of the STEM workforce in 2021, according to the National Center for Science and Engineering Statistics. A 2021 Pew Research analysis found that Black and Latino adults are less likely to earn STEM degrees than degrees in any other field, and they make up a lower share of STEM graduates compared to other populations.

Jason Gibson at community event recruiting students and tutors for Hood Code.

“I think the passion, the drive that these kids have is something that you don’t see in your ordinary kid, because I know that they had to work 10 times harder to be here,” Ogbonna said.

With $200,000 from The David Prize , a no-strings-attached award given to New York-based innovators that the organization won in 2022, Gibson said he is more determined to continue expanding Hood Code’s programming.

“I wish people knew about some of the creativeness that the students have, the ambitions that the students have, the abilities that the students have, and the interests,” Gibson said. “I think people have stereotypes or their own beliefs about neighborhoods like these in general, and a lot of times they’re wrong.”

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Maya Eaglin is a digital reporter for NBC News' "StayTuned" on Snapchat. 

Nicolle Majette is an associate producer for NBC News Now.

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A majority of family medicine visits should qualify for the visit complexity add-on code. Here's how to start using it in your practice.

THOMAS J. WEIDA, MD, FAAFP, AND JANE A. WEIDA, MD, FAAFP

Fam Pract Manag. 2024;31(2):6-10

Author disclosures: no relevant financial relationships.

cpt code for return visit

Primary care is unique in that it is based on an ongoing relationship with patients. Effective Jan. 1, 2024, traditional Medicare (and some Medicare Advantage plans) will recognize the value of that relationship by reimbursing for HCPCS code G2211, which clinicians can add on to an office/outpatient visit evaluation and management (E/M) code. G2211 documents that the longitudinal relationship has complexity beyond that captured in the work of standard E/M codes. This complexity exists for chronic care and even some acute care visits. The deciding factor is the continuing relationship between the clinician and the patient.

DEFINITION OF G2211

The Centers for Medicare & Medicaid Services (CMS) defines G2211 as follows:

Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.) 1

There are two aspects to this definition. The first part underscores that the basis for G2211 is not the patient's clinical condition but the clinician's continued responsibility for the patient. The second part acknowledges that an ongoing relationship may exist for a single, serious condition or a complex condition even if the clinician is not the focal point for all services; CMS provides the example of a patient with HIV who receives ongoing care from an infectious disease doctor. 2

CMS created the new G2211 add-on code to recognize that the longitudinal relationship with a patient has complexity beyond that captured in the work of standard E/M codes.

Code G2211 can be added to office/outpatient E/M visits (99202-99205 or 99211-99215) based on the clinician's continued responsibility for the patient, not based on the patient's clinical condition.

Additionally, even if the clinician is not the focal point for all services for the patient, an ongoing relationship may exist for a “single, serious condition or a complex condition,” justifying use of G2211.

USING G2211

G2211 may only be added to a new or established patient office/outpatient visit E/M code (99202-99205 or 99211-99215). It may be added whether medical decision making or time is used to select the level of service. G2211 may be used for either chronic care visits (with no minimum number of chronic conditions needed to qualify) or acute visits as long as a longitudinal relationship exists or will exist with the patient. Therefore, a new patient visit can qualify when the patient will be establishing with the clinician as their medical home, and an acute care visit with an established patient can qualify if the clinician's practice serves as the continuing focal point for all needed health care services.

CMS has not required any additional documentation to support code G2211. However, if there might be any doubt about the longitudinal patient relationship (or intent to provide longitudinal care), it may be helpful to demonstrate it in the visit note. Particularly for acute problems, documenting the longitudinal relationship's impact on the acute visit could be helpful. For example, the assessment and plan could read as follows: Influenza A, X prescribed, call if not improved in X days; make an appointment to return for influenza immunization in about 2 weeks; next visit as needed for new or worsening problem, already scheduled annual wellness visit .

G2211 may also be used in instances where a “patient's overall, ongoing care is being managed, monitored, and/or observed by a specialist for a particular disease condition.” 1 G2211 is an add-on code to the E/M visit, and modifier 25 does not need to be added to the E/M code. (In fact, G2211 cannot be billed if the visit requires modifier 25; see the exclusions section below.) G2211 can be billed with an office visit E/M service provided via telehealth.

EXAMPLES WHERE G2211 WOULD QUALIFY

A 65-year-old established patient on Medicare whom you have been treating for diabetes, hypertension, and hyperlipidemia presents to your office for a routine check. You order an A1C, comprehensive metabolic panel, lipid panel, and urine for microalbumin, and you adjust the patient's blood pressure medication. This would qualify for a 99214 E/M code as well as the G2211 add-on code because you have an ongoing relationship with the patient.

A 72-year-old patient on Medicare who is new to the practice visits your office to establish ongoing care and also has sinus congestion. This would qualify for an appropriate E/M code as well as the G2211 add-on code. In this example, “the complexity that code G2211 captures isn't in the clinical condition — the sinus congestion.

The complexity is in the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” 3 The intent to establish ongoing care for this new patient suffices.

A 68-year-old established patient who sees you yearly for a Medicare annual wellness visit and periodically for acute problems presents at this visit with complaint of a cough and concern for influenza. You order a rapid test for influenza and recommend influenza vaccination after the patient recovers from this illness and each season thereafter. This would qualify for an appropriate E/M code as well as the G2211 add-on code because you serve as the continuing focal point for all of the patient's health care.

An endocrinologist has been managing a Medicare patient's uncontrolled diabetes and complications for years, and the patient returns for a recheck. This would qualify for an appropriate E/M code as well as the G2211 add-on code because the physician has an ongoing relationship with the patient that involves care of a “single, serious condition or a complex condition” (diabetes, in this instance).

CMS will not pay for G2211 when the E/M service is reported with modifier 25 (significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service). 4 The intent was to exclude G2211 from instances where minor procedures are performed on the same date as an office visit, which often occurs outside of primary care and does not reflect the visit complexity and ongoing relationship otherwise envisioned by G2211. In those instances, CMS considers the additional work and complexity to be part of the procedure code. Unfortunately, the unintended effect of CMS's decision is to exclude the use of G2211 in primary care when modifier 25 is applicable, such as medication administration (e.g., 96372) or spirometry (e.g., 94010 or 94060) in addition to an E/M service. CMS may make additional clarifications on this issue in upcoming rules as they monitor the use of G2211 and have further discussions with interested parties.

Because G2211 may only be reported in addition to office/outpatient E/M visits (99202-99215), it cannot be attached to Medicare annual wellness visits or transitional care management visits. Complexity is already factored into the work and codes for these visits. G2211 also cannot be added to any non-office-visit E/M codes, such as inpatient, emergency department, nursing home, or home visit codes. G2211 would not be appropriate for most urgent care center visits, given the one-off nature of those encounters.

Additionally, CMS considers G2211 to be inappropriate when the visit “is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature; such as, but not limited to, a mole removal” — unless comorbidities are present or addressed, or unless the clinician has taken (or plans to take) responsibility for ongoing care for the patient. 5

CMS has not clarified in writing whether G2211 can be billed by a physician covering for a colleague who is the patient's ongoing source of care or by a nonphysician provider billing for an acute visit with a patient whose ongoing physician is in the same practice. However, based on statements from CMS staff at a Jan. 24, 2024, Open Door Forum , CMS seems inclined to think of clinicians in the same specialty and same group interchangeably for purposes of reporting G2211. (We will update the online version of this article when CMS publishes more guidance.)

EXAMPLES WHERE G2211 WOULD NOT QUALIFY

A 65-year-old established patient on Medicare whom you have been treating for diabetes, hypertension, and hyperlipidemia presents to your office for a routine check. You order an A1C, comprehensive metabolic panel, lipid panel, and urine for microalbumin, and you adjust the patient's blood pressure medication. You also order injection of a medication reported with 96372. This would qualify for a 99214 but would not qualify for G2211 because adding the injection code, 96372, requires that you add modifier 25 to the E/M code.

A 67-year-old Medicare patient sees you for a subsequent Medicare annual wellness visit. G2211 cannot be added because the proper code for this visit is G0439, a HCPCS code, which is not one of the applicable E/M codes. If you had provided the annual wellness visit in addition to an office/outpatient E/M service, modifier 25 would have been required, which would also disqualify the visit for code G2211.

A 70-year-old Medicare patient sees a gastroenterologist for a screening colonoscopy exam without expectation of an ongoing relationship. G2211 cannot be added as there is no ongoing relationship established (or expected to be established).

G2211 DOs AND DON'Ts

Do use G2211 for:

✓ Office/outpatient E/M visits (99202-99205 or 99211-99215) if you are the “continuing focal point for all needed health care services” for the patient, whether the condition is acute or chronic. (If you are not the continuing focal point, use G2211 only if you provide ongoing care for a serious or complex condition.)

Don't use G2211 for:

✗ Non-office E/M visits,

✗ Urgent care center visits (i.e., one-off visits),

✗ Transitional care management visits,

✗ Medicare annual wellness visits,

✗ Visits requiring modifier 25 (i.e., services that when reported on the same date as an office/outpatient E/M service necessitate adding modifier 25 to the E/M code). Examples:

  • Annual wellness visit (G0438-G0439),
  • Injection of medication (96372),
  • Spirometry, inhalation treatment, or other pulmonary function services (94010-94799),
  • Osteopathic manipulative therapy (98925-98929),
  • Annual alcohol misuse screening (G0442),
  • Annual depression screening (G0444),
  • High-intensity behavioral counseling to prevent sexually transmitted infection (G0445),
  • Annual, face-to-face intensive behavioral therapy for cardiovascular disease (G0446),
  • Face-to-face behavioral counseling for obesity (G0447).

USE IN FAMILY MEDICINE RESIDENCY PROGRAMS

Unlike many other specialty residency programs, where patients may see different residents but the same attending physician who is established with the patient and bills for the visit, family medicine patients may see the same resident but have multiple attending physicians who bill for the visits. G2211 is not included in the primary care exception, so that would suggest that in order to use this code for visits that normally qualify for the primary care exception (straightforward and low complexity medical decision making), the attending physician would also need to see the patient. CMS has offered no written guidance in this area. However, at the Jan. 24 Open Door Forum , CMS staff suggested that guidance may be forthcoming allowing G2211 to be billed with E/M services on the primary care exception list if the resident is serving as the focal point for the patient's care.

Until specific guidance is released, given the intent of CMS to recognize the value of the longitudinal relationship between the physician and patient, the following billing practices seem appropriate. If the patient sees the resident who usually provides their care, then it would seem appropriate to use G2211. This would apply to continuity of care issues or acute issues where ongoing care influences the decision-making. If a resident doesn't usually see the patient for care but is seeing the patient for a continuity-type visit, it would seem appropriate to use G2211, as billing would be submitted under one Tax Identification Number (TIN) for the residency practice. Additionally, this would fulfill the intent of the longitudinal relationship for the practice. It would be important for the resident to document the ongoing relationship they have with the patient or the impact the patient's total health has on the current issue. The attending physician would also need to see the patient and document appropriately. Again, this is simply what seems appropriate given the intent of the code, but we look forward to guidance from CMS.

Medicare's national payment amount for G2211 is $16.05; the actual allowance will vary geographically. This value will be subject to the patient's deductible and coinsurance. A Medicare patient often has a 20% coinsurance; therefore, if this code reimburses $16, the patient will be responsible for $3.20. Practices should be prepared to explain to patients what this additional charge is.

CMS estimates that practices will use G2211 with more than half of office/outpatient E/M services once physicians become familiar with the code. So, assuming you provide 20 visits per day, 200 days per year, and half of your visits qualify for the new code, it could bring in $32,080 per year. Some Medicare Advantage plans may pay for this code, while others may consider the work to already be included in capitation rates or other services paid to the practice. Private insurers' coverage of G2211 will also vary because it is not a CPT code, but a Medicare HCPCS code. Each individual insurer sets its own payment policy, just as each state sets its own Medicaid payment policy.

OVERALL, IT'S A WIN

Although limited by legislative actions and budget neutrality, CMS is recognizing the contribution primary care (and other longitudinal care that consists primarily of E/M services) makes to the overall management of Medicare patients. The visit complexity add-on code, G2211, will be valuable for family physicians. Given that Medicare will be paying less per visit in 2024 because the Medicare RVU conversion factor has decreased by $1.14 per RVU, adding this new code will provide a positive net payment for office/outpatient E/M visits. Practices should check the payment policies of their Medicare Advantage plans and private insurers to determine whether they will be paying for this code.

Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. 88 FR 78970. https://www.federalregister.gov/d/2023-24184/p-1379

Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. 88 FR 78974. https://www.federalregister.gov/d/2023-24184/p-1397

How to use the office & outpatient evaluation and management visit complexity add-on code G2211. MLN Matters , 13473. Jan. 18, 2024.

Current Procedural Terminology 2024 Professional Edition. American Medical Association. Appendix A:971.

Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. 88 FR 78971. https://www.federalregister.gov/d/2023-24184/p-1385

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    Step 1: Total time. Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if ...

  2. Coding "Routine" Office Visits: 99213 or 99214?

    Data show that family physicians choose 99213 for about 61 percent of visits with established Medicare patients and choose 99214 only about 23 percent of the time for the same type of visit.1 So ...

  3. List With Office Visit CPT Codes (New & Established Patients)

    Short description: 15-29 minute office visit for new patient evaluation and management. CPT Code 99203. Long description of CPT 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is ...

  4. Office/Outpatient E/M Codes

    Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. 99204. Office or other outpatient visit for the ...

  5. E/M coding for outpatient services

    Note: The article below was posted in 2020 and applies to coding for 2020 dates of service. For information about coding office and other outpatient E/M services in 2021, Please see 99202-99215: Office/Outpatient E/M Coding in 2021.. Evaluation and management (E/M) coding is a high-volume area of CPT ® medical coding, meaning that healthcare providers report E/M codes often on medical claims.

  6. The 2021 Office Visit Coding Changes: Putting the Pieces Together

    The American Medical Association (AMA) has established new coding and documentation guidelines for office visit/outpatient evaluation and management (E/M) services, effective Jan. 1, 2021. The ...

  7. CPT® code 99213: Established patient office visit, 20-29 minutes

    CPT® code 99213: Established patient office or other outpatient visit, 20-29 minutes. As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care. These codes, among the rest of the CPT code set, are clinically valid and updated on a regular basis to ...

  8. Office/Outpatient E/M Visit Coding Changes

    New Guidelines, New Codes. Physicians and other practitioners who are paid under the Medicare Physician Fee Schedule (MPFS) bill for common office or other outpatient visits for evaluation and management (E/M) services using a set of Current Procedural Terminology (CPT)* codes that distinguish visits based on the level of complexity, site of ...

  9. CPT code

    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 ...

  10. CPT Code 99202: Billing Guide & Reimbursement Rates [2024]

    99202 Description: Office or other outpatient visit for the evaluation and management of a new patient which requires a medically appropriate history and/or examination and straightforward medication decision making. (CPT Code 99202 Reimbursement Rate (Medicare, 2024): $71.06. In the past years, this E/m code has been paid $73.97 by Medicare in 2021.

  11. PDF CPT® Evaluation and Management (E/M) Code and Guideline Changes

    and/or descriptors. For this reason, code numbers and/or descriptor language in the CPT code set may differ at the time of publication. Classification of Evaluation and Management (E/M) Services The E/M section is divided into broad categories, such as office visits, hospital inpatient or observation care visits, and consultations.

  12. Documenting Patient Return Visits and Following Up on Missed

    As every patient visit concludes with a documented office visit encounter, the visit note should include when the patient is advised to return. The suggested return visit (i.e. f/u in 2 weeks, 1 month) should be documented in the Action or Plan portion of the progress notes and the patient instructed to make a follow-up appointment before ...

  13. Jurisdiction M Part B

    New Patient Office Visit (E/M) Services (CPT® 99201-99205) — Documentation Requirements. CPT® Code. Description. Documentation Requirements. 99201. Typically 10 minutes. Problem-focused history. Problem-focused exam. Straightforward medical decision-making.

  14. Clear the Confusion about New Patient CPT Code Range

    CPT Code 99202. This code describes a level 2 new patient visit that requires a low level of medical decision-making. The typical time for this visit is 20 minutes. Documentation requirements for new patient CPT code 99202 are as follows: History: Expanded problem-focused history. Exam: Expanded problem-focused exam.

  15. Coding office visits the easy way

    An E/M office visit may be coded based solely on face-to-face time when more than half is devoted to counseling or coordination of care. ... CPT code Typical time; 99211: 5 minutes: 99212: 10 ...

  16. CPT® code 99204: New patient office visit, 45-59 minutes

    CPT® code 99204: New patient office or other outpatient visit, 45-59 minutes. As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care. These codes, among the rest of the CPT code set, are clinically valid and updated on a regular basis to ...

  17. Recommended Ways to Document and Report a Preventive Visit

    CPT® Code: Description: 99381: Initial comprehensive preventive medicine evaluation and management, new patient; infant (age younger than 1 year): 99382 early childhood (age 1 through 4 years) 99383 late childhood (age 5 through 11 years) 99384 adolescent (age 12 through 17 years) 99385 18-39 years 99386 40-64 years 99387 65 years and older

  18. When to Use Post-Op Modifiers 58, 78, 79

    Modifier 58 may be used during the global surgical period for the original procedure only. It may not be used for staged procedures when the code description indicates "one or more visits" or "one or more sessions.". Note that Medicare requires a return to the operating room (OR) to apply post-op modifier 58, "unless the patient's ...

  19. Association of Time-Based Billing With Evaluation and Management

    Length of return visit, min: 15: No. of new visits per year: 553: No. of return visits per year: 5934 % Return visits billed at CPT code 99211: 1.64: No. of return visits billed at CPT code 99211: 97: Billing rate of CPT code 99211 visits, $ 23.03: Yearly revenue from CPT code 99211 visits, $ 2236: Sample calculation of time-based billing revenue

  20. Outpatient E/M Coding Simplified

    As a result of the changes to medical decision making and time-based coding, the RUC revised the 2021 relative value units (RVUs) for office visit E/M codes. Most of the values increased, yielding ...

  21. Patient Returning for a Repeat Pap Smear? Zero In on the E/M Visit

    When the patient comes in for a second Pap smear, submit the appropriate E/M service. CPT® does not include a code for taking the Pap, so you should use the office visit code (99211-99215). You will probably report 99212 for the Pap retest visit because the patient is here only for the Pap smear. That translates to almost $57 per visit, using ...

  22. Gerrit Cole injury update: Yankees ace to miss 10-12 weeks with elbow

    Following the visit, ... without saying that losing Cole for any length of time would be a devastating blow to a Yankees team that is trying to return to the postseason after going 82-80 in 2023 ...

  23. Peach State CB Planning Return After Strong Clemson Visit

    A coveted Peach State defensive back was impressed with his first experience at Clemson. Three-star cornerback Kaleb Lanier visited for the Elite Junior Day and it's a visit that he's been excited about for months. Lanier's connection with the Tigers dates back to an in-school visit from cornerbacks coach Mike Reed at Decatur High School.

  24. Combining a Wellness Visit With a Problem-Oriented Visit: a Coding

    Once you've documented your MDM, you can bill an E/M visit using codes 99202-99215 with the preventive medicine visit code. Make sure to add modifier 25 to the E/M code to signal to the payer that ...

  25. This group brings free coding education to low-income NYC students

    Hood Code is an organization that provides free coding classes to students who live in New York City's public housing. These apartments are home to more than half a million low-income families ...

  26. From Antepartum to Postpartum, Get the CPT® OB Basics

    For example, a provider performs one antepartum visit to an established patient. The visit includes an expanded, prob-lem-focused history and exam, with medical decision-making (MDM) of low complexity. ... and is claiming no antepartum or postpartum care, report the appropriate delivery-only CPT® code and append modifier 80 Assistant surgeon ...

  27. G2211: Simply Getting Paid for Complexity

    The visit complexity add-on code, G2211, will be valuable for family physicians. Given that Medicare will be paying less per visit in 2024 because the Medicare RVU conversion factor has decreased ...