CPT 99212, 99213 visit history

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

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

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

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

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

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

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

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.

comparison of CPT 99212 & 99213

CPT 99212 vs 99213

There is set of Evaluation and Management Guidelines that appear every year that the provider must become aware of. There are several physicians who might be wondering whether to use coding 99212 or 99213 this will help you to go through any ecision making process that is conducted without much difficulty.


The three things that one must keep in mind for the selection of the right E/M code are:

1. History

2. Exam

3. Decision making

When you consider CPT codes 99212 to 99215 they require that only two of the three key components meet or exceed the level of code that is chosen.

The Review of Systems (ROS) is the key difference between a PF (99212) and an EPF (99213) history. The CPT 99212 does not require a ROS and documentation.

The ROS is a list of signs or symptoms a patient has had in the past, or currently may be experiencing. It is not, per se, a list of previously diagnosed diseases. Previously diagnosed diseases are considered a different portion of the history called past diseases. The ROS serves a number of different functions. If a complaint is new to the physician, the ROS are the questions asked to aid the physician in arriving at a diagnosis related to various organ systems. Often this is helpful in eliminating a diagnosis from the differential diagnosis.

All medically necessary E/M encounters performed by a physician involve at least straightforward decision-making because straightforward decision-making is the lowest level possible. That is all that is required for a CPT 99212.

The three equal elements of medical decision making are:

1. The amount of data and medical records reviewed

2. The number of diagnoses or treatment options.

3. The risk associated with  mortality or morbidity of a treatment option, diagnosis, or procedure. The highest level of risk associated with a procedure, problem, or management option determines the level of risk.

Only two of the three elements need to meet or exceed the level of decision-making which is selected.

If the level of history is counted as one of the two key components, for example a problem focused (PF) history, this is all that is required for the documentation of a CPT 99212.

You must always keep in mind the “Medical Necessity” of the visit is the highest priority for your final coding choice.

CPT code 99354 – Prolonged Visit

CPT 99354 – Prolonged physician service in the office or other outpatient setting, requiring direct (face-to-face) patient contact beyond the usual service – first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)

The average reimbursement is in the range of $95.00, depending upon your region.

The Medicare Manual says:
The start and end times of the visit shall be documented in the medical record along with the date of service.

This code is one of many under-utilized codes in your office for many reasons. However, if you do the work and spend the prolonged time, face to face with the patient, document the progress note properly and provide the required medically necessary components, you deserve to use this code and get paid for your time.

Serious Illness Takes Serious Time

This code can be used for a seriously ill patient in your office, when you are spending a significant amount of time helping, while deciding the best course of action. This would include deciding to admit the patient to the hospital or sending the patient to the emergency room via a 911 call.

Usually, if you are spending over 40 minutes with the patient and have all of the criteria, you are going to document and bill for a 99215.  However, if you end up spending any additional time, for example, over another 30 minutes with the patient, and your face-to-face total time counting all other services is 75 minutes or more, you may be entitled to capture the additional CPT code 99354.

Record Your Time!

It is prudent to report the start times and the ending times as well as the face-to-face time, in order to properly capture this code.

Overall, this really is not that difficult.  For example, if you have a patient who comes into your office with an exacerbation of their COPD, you may start the patient on oxygen in your office while you perform your History, Physical and Medical Decision Making.

Keep Track of the Intensity of your Care

In the course of this you may order a nebulizer treatment for the patient and then leave the room to see another patient, you should document the time actually spent with the patient up to that point.
Once you return to the room the clock starts again. While speaking with the patient regarding how they feel after the nebulizer treatment, you may decide that they need an injection or another treatment. You document the time and then may have to leave the room to see another patient.

Once you return to the room, the clock starts again; so each time you decide on a treatment option for this patient, you continue to accrue time towards, not only the level CPT 99215 visit as the patient definitely will meet criteria for the intensity and medical necessity, you are potentially capturing the extra time needed to use the CPT 99354 code.
This code will enable you to be able to bill for the extra time you need to spend with the patient while you are stabilizing them, in order to decide if they can return home be transported to the hospital.

Many of us have the occasional patient who will use a significant amount of time in order for you to take proper care of them, to stabilize them and to decide whether the current problem they have can be handled from home or in the hospital.

Code Correctly for your Visit Too

If you provide the care, you deserve the code. That is why it is available in the first place. You owe it to yourself to maximize your revenue. Many providers will only bill this encounter as a CPT 99213 or CPT 99214. The reality is, if you do the work and properly document with the medical necessity in place, you can easily and comfortably bill for the appropriate code CPT 99215 and CPT 99354.

EHR incentive payment - How to register

Registration Eligible Professional

Registration at the national level for the Medicaid EHR Incentive Program opened in January 2011. However, the Medicaid EHR Incentive Program is administered individually by each state, therefore registration start dates vary from State to State.

Eligible professionals are required to register on the national level through the CMS website and at the state level in Florida.

STEP1
Register on the CMS Medicare and Medicaid EHR Incentive Program Registration and Attestation System.

For the most up-to-date information about registration into the CMS Medicare and Medicaid EHR Incentive Program Registration and Attestation System click here.

Eligible Providers will need to complete the following in order to complete registration:

• Meet the eligibility requirements (Be in one of the eligible professions; meet the minimum Medicaid patient volume, etc.)
• Be fully enrolled as a Florida Medicaid Provider

• Have a Florida Medicaid Provider Number and PIN in order to access the Medicaid Secure Area
• Have a National Provider Identifier (NPI) number.

• Have a National Plan and Provider Enumeration System (NPPES) web user account ID and Password (https://nppes.cms.hhs.gov/NPPES/Welcome.do)
• Have an EHR Certification Number (http://onc-chpl.force.com/ehrcert)

 STEP 2

Florida registration has begun. For assistance in registering call the EHR Incentive Payment Program Contact Center at 1(855) 231-5472 or view the User Guide for Eligible Professionals. Incentive Program staff have created a template to help you capture the information needed to determine volume.  If you chose to use the template, please upload it as part of your application as it will assist the Agency in your pre-payment validation process

ERX payment adjustment 2012

Assessing and Applying the 2012 eRx Payment Adjustment 2012 eRx Assessment

An eligible professional who meets the eRx program inclusion criteria will be subject to the 2012 eRx payment adjustment if (s)he did not submit the following:

• 10 valid 2011 eRx G-codes (G8553) via claims during the 6-month reporting period of January 1, 2011 – June 30, 2011; or

• A hardship exemption (G8642, G8643) via claims during the 6-month reporting period; or

• A G-code via claims indicating (s)he did not have prescribing privileges (G8644) during the 6-month reporting period; or

• (S)he requested and was granted a hardship exemption through the Quality Reporting Communication Support Page.

CMS analysis of all valid 2011 eRx QDCs submitted with a Date of Service during the 6-month reporting period determines whether or not the payment adjustment applies to the eligible professional.

Group practices participating in eRx GPRO who would be subject to the payment adjustment is defined as a TIN who:

• Failed to meet the 2011 eRx criteria for successful reporting during the 6-month reporting period of January 1–June 30, 2011; or

• Failed to indicate a hardship or lack of prescribing privileges to CMS

The analysis of successful reporting for group practices that participate in eRx GPRO will be performed at the TIN level to identify the group’s services and quality data. All NPIs under the TIN during the 6-month reporting period for 2011 (January 1, 2011 – June 30, 2011) will receive the payment adjustment if the group practice participating in eRx GPRO is subject to the payment adjustment.

For eligible professionals who submitted claims under multiple TINs, CMS groups claims by unique TIN/NPIs for analysis and payment adjustment purposes. As a result, an eligible professional who submitted claims under multiple TINs may be subject to an eRx payment adjustment under one of the TINs and not the other(s), or may be subject to a payment adjustment under each TIN.

Who is eligible for 2012 ERX incentive

2012 Electronic Prescribing (eRx) Payment Adjustment: Assessment and Application


An eligible professional was included in the 2012 eRx payment adjustment analysis if  they meet all of the following criteria:

• Was a physician (MD, DO, or podiatrist), Nurse Practitioner, or Physician Assistant as of June 30, 2011, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES);

• Had prescribing privileges from 1/1/11-6/30/11;

• Had at least 100 cases containing an encounter code in the measure’s denominator from 1/1/11-6/30/11; AND

• Had 10% or more of their Medicare Part B allowable charges (per Tax Identification Number (TIN)) from 1/1/11-6/30/11 were for encounter codes in the measure’s denominator

Eligible professionals were automatically excluded from the 2012 eRx payment adjustment analysis if they did NOT meet one of the above criteria. In addition, eligible professionals could have taken the following steps from to avoid the 2012 eRx payment adjustment:

• Submitted 10 or more 2011 eRx quality-data codes (G8553) for Medicare Part B PFS services via claims from 1/1/11-6/30/11;

• Indicated that the eligible professional met criteria for a hardship exemption for either living in a rural area without sufficient high speed internet (G8642), or practiced in an area without sufficient pharmacies that can accept eRx (G8643) via claims from 1/1/11-6/30/11;

• Indicated that the eligible professional did not have prescribing privileges (G8644) via claims from1/1/11-6/30/11; OR

• Requested a hardship exemption via the Quality Reporting Communication Support Page on or before 11/8/11, and received CMS approval.