CPT CODE 99213 - Billing rules And Guideline

Procedure code and description

99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.  - average fee amount - $75 - $90

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

CPT CODE - 99213 Established patient, moderate clinic visit.

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

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

o An expanded problem focused history

o An expanded problem focused examination

o Medical decision making of low complexity

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


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

The descriptors for the levels of E&M services recognize seven components, six of which are used in defining the levels of E&M services. These components are:

1. History (key component); four recognized types of history (problem-focused, expanded problemfocused, detailed, and comprehensive)

2. Examination (key component); four recognized types of examination (problem-focused, expanded problem-focused, detailed, and comprehensive)

3. Medical decision-making (key component); four recognized types of medical decision-making (straightforward, low complexity, moderate complexity, and high complexity)

4. Counseling (contributory factor)

5. Coordination of care (contributory factor)

6. Nature of presenting problem (contributory factor)
7. Time

When selecting the appropriate level of service for an Office Evaluation and Management (E/M) CPT code, the following requirements must be satisfied and adequately documented in the clinical record:

• New Patient (CPT 99201-99204) – requires all three key components
• Established Patient (CPT 99212-99214) – requires two of the three key components



Billing and Coding Tips


If Breath hydrogen test was performed on the same day of E/M visit 99213, use CPT 91065 and append 25 modifier to office visit

If E & M services and surgery are done on same DOS we need to append 25 modifier for E & M 99213 -25 services


Billing with Flu vaccine on same day, add modifier.

99213-25
90471
90658

•CPT 94760 is a non-covered/inclusive procedure if it is performed along with 99201-99205 or 99211-99215 and 99241-99245 on the same date of service. Please write off CPT 94760 in such cases. Please note that the CPT 94760 should be paid if the same is performed alone on a particular DOS.


If Pneumococcal Vaccine given on same day with  – 90732

E&M:           99214 – 25
Vaccine:       90732
Admin code: G0009
ICD:  V03.82


Office visit Procedure to Bill EKG along with E & M

93000 when performed in Office
99213 – 25
93000 – 59


If you aware of some rule then use comment section to help others


Billing Examples

Examples of billable and non-billable prolonged services follow.

• Billable Prolonged Services

EXAMPLE 1

A physician performed a visit that met the definition of an office visit CPT code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills CPT code 99213 and one unit of code 99354.


Can medical procedure codes 99393 and 99213 be billed together 

Ans : Yes.

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

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

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


Billing 99213 with surgical procedure and modifier usage

* Procedure code 27447 has a global surgery period of 90 days.

* Procedure code 99213 is submitted with a date of service that is within the 90-day global period.

* When a substantial diagnostic or therapeutic procedure is performed, the evaluation and management service is included in the global surgical period.

Example: evaluation and management service submitted with minor surgical procedures

Code Description Status

11000 DOS=01/23/10 Debridement of extensive  eczematous or infected skin;  up to 10% of body surface.

Allow 99213 DOS=01/23/10 Office or other outpatient  visit for the evaluation and  management of an EST patient,  which requires at least two  of these three 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  providers or agencies are provided  consistent w/ nature of problem(s)  and patient’s and/or family’s needs.  Problem(s) are low/moderate severity.  Physicians spend 15 minutes  face-to-face with patient  and/or family. Disallow

Explanation:

** Procedure 11000 (0-day global surgery period) is identified as a minor procedure.

** Procedure 99213 is submitted with the same date of service.

** When a minor procedure is performed, the evaluation and management service is considered part of the global service.

NOTE:

MODIFIER – 24 is used to report an unrelated evaluation and management service by the same physician during a postoperative period.

MODIFIER – 25 is used to report a significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure. MODIFIER – 79 is used to report an unrelated procedure or service by the same physician during the post-operative period. When MODIFIERS – 24 AND – 25 are submitted with an evaluation and management service on the same date of service or during the post-operative period by the same physician, the evaluation and management service is questioned and a review of additional information is recommended. When MODIFIER – 79 is submitted with an evaluation and management service on the same date of service or during the post-operative period by the same physician, separate reporting of the evaluation and management service is recommended. MODIFIERS – Modifiers are added to the main service or procedure code to indicate that the service has been altered insome way by a specific circumstance.


Documentation for these services may include, but not limited to: 

  • Progress notes for the date(s) of service in question
  • Written/telephone physician orders
  • An example of the provider's signature
  • If the signature on the documentation supporting the service is missing or illegible, please submit an attestation statement from the performing provider verifying that they personally performed the service(s).  
  • The procedure report or other applicable documentation if the E/M was billed with the 25 modifier, indicating it was separately identifiable from the procedure
  • Any other type of documentation to substantiate the medical necessity for the particular service(s)

Billing Error Example of  Billed CPT 99213 - E/M established patient requiring 2 of 3 key components (expanded history and low complexity medical decision making) was billed under the physicians NPI. This service is being billed "Incident To" as the documentation for this date of service supports the service was performed by a nurse practitioner. The note shows this as a follow-up visit for Fibromyalgia/Chronic Fatigue/Right Lower Extremity Pain and to assess the patient after starting medication.

The handwritten notes indicate previous visits with the reason for the visit documented and a note for a subsequent visit for f/u start Savella. The documentation does not indicate any physician oversight or previous visits by the physician initiating the course of treatment. Based on the documentation, it seems to be a follow-up visit with the NP who started the patient on this medication previously.


Examples of billable and non-billable prolonged services follow.  

Billable Prolonged Services 

EXAMPLE 1

A physician performed a visit that met the definition of an office visit CPT code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills CPT code 99213 and one unit of code 99354.

EXAMPLE 2

A physician performed a visit that met the definition of a domiciliary, rest home care visit CPT code 99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills CPT codes 99327, 99354, and one unit of code 99355.

EXAMPLE 3

A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician bills CPT code 99215 and one unit of code 99354.

 Non-billable Prolonged Services

EXAMPLE 1

A physician performed a visit that met the definition of visit code 99212 and the total duration of the direct face-to-face contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct face-toface service did not meet the threshold time for billing prolonged services.

EXAMPLE 2

A physician performed a visit that met the definition of code 99213 and, while the patient was in the office receiving treatment for 4 hours, the total duration of the direct face-to-face service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.

EXAMPLE 3

A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

Finally, you should remember that Medicare contractors will not pay (nor can you bill the patient) for prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls). These are Medicare covered services and payment is included in the payment for other billable services.

Evaluation & management tips: Office or other outpatient services, established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:

1. History
2. Examination
3. Medical decision-making.

When billing office or other outpatient services for established patients, two of the three key components must be fully documented in order to bill (other than 99211). 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.

Comparision of other Established code 99211, 99212, 99213, 99214, 99215

99211 - 5 minutes (average)

• Patient presenting with minimal problems
• Three components not required

99212 - 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 (two of three 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


99213 - 15 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 of low complexity. Documentation needed (two of three 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

99214 - 25 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 moderate complexity. Documentation needed (two of three 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


99215 - 40 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and 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 eight or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (two of three 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




Can medical procedure codes 99393 and 99213 be billed together 

Medicare fee amount for CPT CODE 99213

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