CPT 99212, 99213 visit history

CPT 99212 checklist

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

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


Type of History : Problem focused
HPI : Brief (1-3 element)
Examinaation :
Type of Exam : Problem focused
Details of Examination : Limited-affected area or organ system
Medical Decision Making
Type : Straight forward
# of diagnoses/management options: minimal
Amount/complexity of data : minimal
Risk of Cimplications/morbidity/mortallity: minimal


HIP elements (8):
modifying factors

ROS system(14):


Other History areas
(Req. for 99203/14 & up)
past history
family history
social history

Details of Examination

body areas:
head, including face
chest, inc. breasts, axillae
genitalia, groin, buttocks
back, including spine
each extremity

organ systems:
(vital signs, general)
ears, nose, throat, mouth


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

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

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

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

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

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

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

Time-based billing

Another option for coding level-II and level- III encounters is to use time as your guide. According to CPT, a typical level-II visit lasts 10 minutes, while a typical level-III visit lasts 15 minutes. If counseling or coordination of care account for more than 50 percent of the visit, then you can select your E/M code based on the length of the visit. In general, the time spent face-to-face with the patient (and the time spent in counseling) should meet or exceed the listed typical visit times. Remember,

the coders who audit your charts do so by counting required components as well as noting recorded visit times. If you decide to use time-based billing, make sure to include in your note that at least half of the face-to-face time was spent counseling or coordinating care (e.g., “total visit time was 15 minutes, half of which was counseling”). Your documentation should also describe the nature of the counseling or care coordination.

cpt 99212 hospital

Effective January 1, 2010, CPT consultation codes were no longer recognized for Medicare Part B payment. As explained in CR 6740, Transmittal 1875, Revisions to Consultation Services Payment Policy, issued on December 14, 2009, physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. CMS instructed providers billing under the PFS to use other applicable E/M codes to report the services that could be described by CPT consultation codes. CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians where permitted) who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).

CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with CPT consultation codes and for which the minimum key component work and/or medical necessity requirements for CPT codes 99221 through 99223 are not documented. Providers may report CPT code 99221 for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient.

In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially meet requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. Contractors shall expect changes to physician billing practices accordingly. Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

For 99232 we have to use 99212

cpt 99212 coding examples

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

Then the physician evaluated the knee and performs an arthrocentesis.

Correct Code to be Used: 99212-25 and 20610

Coding Rationale : The evaluation of the knee problem is included in the arthrocentesis reimbursement. The presenting problem for the visit was other than the knee problem. A separate evaluation of the hypertension and diabetes was performed (Grider4) (and would have been performed if the knee problem did not exist), making the use of modifier 25 appropriate

1 comment:

Medical Billing said...

I prefer the outsource medical billing option with Tradeseam.

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