CPT 99211, 99212, 99213, 99214, 99215 and with time value

CPT CODE 99212

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components

 For code 99212, the office or other outpatient visit is for the evaluation and management of an established patient, and requires at least two of these three key components be present in the medical record:

 o A problem focused history

o A problem focused examination;

o Straightforward medical decision making

 A tip for billing 99212 is that the presenting problems are usually self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.


Established patient evaluation and management codes: 99211-99215 IN Chiropractic billing

An established patient is defined as one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. The established patient must have a new condition, new injury, aggravation, or exacerbation that warrants further examination above and beyond what is included in chiropractic manipulative therapy (CMT) services.


Re-evaluations

It is appropriate to bill for the CMT and a re-evaluation if one of the following has occurred:

** The established patient has a new condition, new injury, aggravation, or exacerbation that warrants further examination above and beyond what is included in CMT services, or

* * Periodic re-evaluation to determine if a change in the treatment plan is necessary.

Codes 99211–99215 with a -25 modifier can be billed along with a chiropractic manipulation (98940–98942) every three months (or if the patient has a new complaint/exacerbation of their condition) for a total of four re-evaluations per year. CMT codes include a pre-manipulation patient assessment component for each visit, which must be supported by appropriate documentation.

If billed inappropriately, the E&M service will be denied and the member cannot be billed.

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. Usually the presenting problem(s) are minimal. Physicians typically spend five minutes face-to-face with the patient and/or family.

CPT 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are self-limited or minor.

Physicians typically spend 10 minutes face to face with the patient and/or family.

CPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history, an expanded problem-focused examination, and medical decision-making of low complexity. Counseling and 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 15 minutes face to face with the patient and/or family.

CPT 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination, and 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 25 minutes face to face with the patient and/or family.

CPT 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of 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 40 minutes face-to-face with the patient and/or family

Billing and Coding Guidelines

• 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-to-face service did not meet the threshold time for billing prolonged services.

• Follow-up visits to a consultation service in the office or other outpatient settings will be reported with the Office or Other Outpatient Established Patient codes 99212-99215.

: Amerigroup only allows CPT 99211 or 99212 to be reimbursed on the same date of service as the Health Check periodic visit in support of an abnormal health check. Interperiodic CPT codes 99201-99205, 99213-99215, 99173, V5008, 92551, 92552, 92553, 92555 and 92556 will deny as incidental to the Health Check periodic visit when billed on the same date of service. Only office visit code 99211 or 99212 with modifiers EP, 25 and the appropriate diagnosis codes can be billed in combination with the Health Check periodic visit.

BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212
99242 to 99212




Bundling Guidelines

BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212
99242 to 99212
99243 to 99213
99244 to 99214
99245 to 99215

Office Visits - Office services provided on an emergency basis (99058) are considered mutually exclusive to the primary services provided.

Office visit (99211) is considered mutually exclusive to 95115-95117(allergen immunotherapy). Separate reimbursement is not allowed for mutually exclusive services. Pap Smears - Obtaining a pap smear is integral to the office visit. This includes both preventive and routine office visits. Separate reimbursement is not allowed for Q0091.

Pathologists - Claims submitted by pathologists (provider specialty 29) for clinical interpretation of laboratory results will be allowed for codes 83020, 84165, 84166, 84181, 84182, 85060, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, and 87207. Pathology interpretation of all other codes in the 80002-87999 range is considered integral to the laboratory test. Separate reimbursement is not allowed for integral services.

Pulse Oximetry - Pulse oximeters are considered incidental to office visits or procedures. Separate reimbursement is not provided for incidental procedures.

Respiratory Treatments - Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB devise is considered mutually exclusive to an office visit. Separate reimbursement is not provided for mutually exclusive services.

Robotic Surgical Systems - Payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.

STAT or After Hours Laboratory Charges - Additional charges for STAT or after hours laboratory services are considered an integral part of the laboratory charge.

Surgical Supplies - Surgical supplies will be considered incidental to Surgical; Laboratory; Inpatient, Outpatient or Office Medical Evaluation and Management; and Consultation services. Surgical dressings applied in the provider’s office are considered incidental to the professional services of the health care practitioner and are not separately payable. Surgical dressings billed in the provider’s office (place of service 11) will be denied.

Surgical trays and miscellaneous medical and/or surgical supplies are generally considered incidental to all medical, chemotherapy, surgery, and radiology services, including those performed in the office setting.

Supplies (except those related to splinting and casting) are considered components of the 0, 10, and 90- day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure.

Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course  of an office visit are generally considered incidental to the office visit.

Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.

Transvaginal Ultrasound - Transvaginal ultrasound (76830) is considered mutually exclusive to a hysterosonography with or without color flow Doppler (76831). Venipuncture - Refer to policy “Code Bundling Rules Not Addressed in Claim Check.”

Vision Services - Determination of refractive state (92015) performed incidental to a medical eye exam is permissible and may be covered when performed outside of any global allowance and subject to member benefits.

X-Rays - When single view and double view chest X-Rays are billed together (71010 and 71020), only the double view X-Ray is allowed. When the entire spine, survey study is billed (72082) with cervical spine films (72040), thoracic spine films (72070) or lumbosacral spine films (72100) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view XRay code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowable per X-Ray.


Time and RVU comparison of 99211, 99212 -99215




CPT Code Description RVU non-facility RVU facility Time in mins
99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a medical practitioner . Usually , the presenting problem(s) are minimal. Typically,5 minutes are spend performing or supervising these services. 0.57 0.24 5
 99212    Office or other outpatient visit for the evaluation and management of an established patient that requires at least two of these three key components: a problem focused history -a problem focused examination -straightforward medical decision making. Counseling and/or co-ordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Medical practitioners typically spend 10 minutes face-to-face with the patient and /or family.    1.02    0.64   10
 99213    Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: an expanded problem focused history-and expanded problem focused examination -medical decision making of low complexity. Counseling and co-ordination 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. Medical practitioners typically spend 15 minutes face-to-face with the patient and/or family.    1.39    0.94   15
 99214    Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history -a detailed examination -medical decision making of moderate complexity . Counseling and/or co-ordination of care with the 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. Medical practitioners typically spend 25 minutes face -to-face with the patient and/or family.    2.18    1.56   25
 99215    Office or other outpatient visit for the evaluation and management of an established patient , which requires at least two of the three key components : a comprehensive history-a comprehensive examination -medical decision making of high complexity. Counseling and/or co-ordination 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. Medical practitioners typically spend 40 minutes face-to-face with the patient and/or family.    3.17    2.50   40

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