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Find-A-Code Articles, Published 2021, September 28
When is it proper to bill nurse visits using 99211.
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS Sep 28th, 2021 - Reviewed/Updated Aug 29th
When vaccines or injections are given in the office, coding can often get confusing; for example, is it correct to report a nurse visit using 99211 and an E/M office visit reporting 99202 ‑ 99215 and include injection fees with the vaccine product? In addition, the reporting of evaluation and management (E/M) during the same visit where vaccines are administered is not always understood. The answer depends on whether the provider performs a medically necessary and significant, separately identifiable E/M visit, in addition to the immunization administration.
CMS states, when a separately identifiable E/M service (which meets a higher complexity level than CPT code 99211 ) is performed, in addition to drug administration services, you should report the appropriate E/M CPT code reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.
It is incorrect to bill a 99211 when the provider provides an E/M service that meets a higher complexity level than CPT code 99211 , you must bill the higher complexity, and you cannot bill for two services in one day.
Charging for Nurse Visits
There are times when it is appropriate to report for a nurse visit using CPT code 99211 . The Incident-to rule applies when reporting this code, and services provided must be documented as medically necessary services, including the clinical history, clinical exam, making a clinical decision, and physician supervision.
- NOTE: A nurse visit is not paid if billed with a drug administration service such as chemotherapy or non-chemotherapy drug infusion code, including therapeutic or diagnostic injection codes. The reasoning is because diagnostic IV infusion or injection services typically require direct physician supervision, and using 99211 is reported by qualified healthcare professionals other than physicians.
08/29/2023 NOTE: (These CPT codes,90782, 90783, 90784, or 90788 were deleted in 2006, but still showing in CMS - Claims processing manual) When reporting CPT codes 90782, 90783, 90784, or 90788 , CPT code 99211 cannot be reported. In addition, it is improper billing to report a visit solely for an injection that meets the definition of the injection codes.
When the only reason for the visit is for the patient to receive an injection, payment may be made only for the injection (if it is covered). An office visit using 99211 would not be warranted where the services rendered did not constitute a regular office visit and a part of the plan of care and not at the patient's request.
Unlike other E/M codes 99202 - 99205 , and 99212 - 99215 , time alone cannot be used when reporting 99211 when selecting the appropriate code level for E/M services. Effective January 1, 2021, time was removed as an available code-selection criterion. The typical time spent on this code is five minutes.
Other visits billed with 99211
Several other visits may be reported using 99211 , and nurses are not the only staff that can report this code; medical Assistants and technicians are also included under non-physician.
Covid-19 Testing
According to CMS ; Physician offices can use CPT code 99211 when office clinical staff furnish assessment of symptoms and specimen collection for Covid-19 incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher-level visit furnished by the billing practitioner, that higher-level visit code should be billed. The specimen collection would not be separately payable.
Examples from CMS
The following are examples of when CPT 99211 might be used:
- Office visit for an established patient for blood pressure check and medication monitoring and advice. History, blood pressure recording, medications, and advice are documented, and the record establishes the necessity for the patient's visit.
- Office visit for an established patient for return to work certificate and advice (if allowed to be by other than the physician). Exam and recommendation are noted, and the Return to Work Certificate is completed, copied, and placed in the record.
- Office visit for an established patient on regular immunotherapy who developed wheezing, rash, and swollen arm after the last injection. Possible dose adjustments are discussed with the physician, and an injection is given. History, exam, dosage, and follow-up instructions are recorded.
- Office visit for an established patient's periodic methotrexate injection. Monitoring Lab tests, query signs and symptoms, obtain vital signs, repeat testing, and injection advised. All this information is recorded and reviewed by the physician. (Note that in this circumstance, if 99211 is billed, the injection code is not separately billable). An office visit for an established patient with a new or concerning bruise is checked by the nurse (whether or not the patient is taking anticoagulants), and the patient is advised on how to care for the bruise and what to be concerned about, and, if on anticoagulants, continuing or changing current dosage is advised. History, exam, dosage, and instructions are recorded and reviewed by the physician.
- Office visit for an established patient with atrial fibrillation who is taking anticoagulants and has no complaints . The patient is queried by the nurse, vital signs are obtained, the patient is observed for bruises and other problems, the prothrombin time is obtained, the physician is advised of prothrombin time and medication dose, and medication is continued at present dose with follow up prothrombin time in one month recommended. History, vital signs, exam, prothrombin time, INR, dosage, physician's decision, and follow-up instructions are recorded.
References/Resources
About christine woolstenhulme, qmc qcc cmcs cpc cmrs.
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
When is it Proper to Bill Nurse Visits using 99211. (2021, September 28). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/nurse-visits-and-injections-36866.html
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Who Can Report 99211?
Defining “nurse” for coding and reporting purposes, what are the documentation requirements for 99211, what is the current policy for reporting 99211, when is it appropriate to report 99211, what about commercial payer policies, clearing the confusion: billing “nurse” visits.
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American Academy of Pediatrics; Clearing the Confusion: Billing “Nurse” Visits. AAP Pediatric Coding Newsletter September 2005; 2005 (4): No Pagination Specified. 10.1542/pcco_book025_document001
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Questions continue to be raised about the appropriate billing of code 99211. Can this level of service be reported by a physician? Would it be appropriate to report a nurse visit when, for example, the nurse administers vaccines or an antibiotic, performs a strep test, obtains blood, reads a purified protein derivative (PPD), or performs a weight check?
The Current Procedural Terminology (CPT ® ) descriptor for code 99211 states, “Office or other outpatient visit for the evaluation and management [E/M] of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.” The key to reporting this service? It must be medically necessary and require a face-to-face E/M service with supporting medical record documentation.
A physician typically does not report this level of E/M. Usually when the visit re-quires a face-to-face with the pediatrician, a minimum of straightforward medical decision making with a problem-focused history or examination is performed and documented. That level of visit would be reported as a level 2 visit (99212) as per CPT guidelines. Certainly a physician can report 99211 when providing a service if that physician feels it appropriate, but most often these types of visits are handled by nurses, allowing the pediatrician time to treat other patients.
The American Nurses Association recognizes that “non-advanced practice nonphysician providers” can diagnosis and/or assess patients, provided it is within the state’s scope of practice laws and meets incident to billing requirements.
When a nurse provides the 99211 visit, it is reported under the physician’s name and tax ID number as an incident to service. The incident to requirements as defined by the Centers for Medicare and Medicaid Services (CMS) are that services must be integral to the physician’s professional service, must be commonly rendered without charge or included in the physician’s bill, must be of a type commonly furnished in a physician office, and are furnished by auxiliary personnel under the physician’s direct supervision. Physician direct supervision is defined as the physician being physically present in the office suite (not in the patient’s room) and immediately available to provide assistance. The patient must be an established patient with the physician involved in the plan of care. Most nurse services are provided under an established protocol developed by the physician for the particular service and should be fully documented. The physician supervising the care must sign the chart entry.
The documentation requirements for 99211 differ from most of the E/M services provided by physicians. There are no required key components (history, physical examination, and medical decision making, or time if more than 50% of the total face-to-face time is spent counseling or coordinating care) and the typical time published in CPT for 99211 is 5 minutes. The American Academy of Pediatrics (AAP) encourages documenting the date of service and reason for the visit, a brief history of any significant problems evaluated or managed, any examination elements (eg, vital signs, appearance of a rash), a brief assessment and/or plan along with any counseling or patient education done, and signatures of the nurse and supervising physician. Documentation should clearly support the medical necessity of the visit.
Per CMS policy, CPT code 99211 cannot be billed solely for the purpose of administering an immunization or injection, collecting a specimen for a diagnostic test, checking vital signs that would not affect the patient’s care, or writing new or renewal prescriptions if no other assessment was performed. Reporting 99211 with these services requires that the service be separate, significant, and medically necessary. The American Medical Association also defines a reportable E/M service as being significant and separate from vaccine administration.
Immunization and drug administration CPT codes (including therapeutic or diagnostic infusions, chemotherapy administration services, and therapeutic, prophylactic, or diagnostic injections) include administrative and clinical services in their Resource-Based Relative Value Scale work values and cannot be billed with a nurse visit when the sole purpose of the visit is for the administration. In other words, these administration codes include taking vital signs, obtaining history related to the vaccine or medication, preparing and administering the medication or vaccine, observation for reactions, and medical record documentation.
The AAP has published a position paper with clear guidelines on billing 99211 with immunization administration. For more information and vignettes on the use of 99211 during immunization administration, visit the Member Center of the AAP Web site, http://www.aap.org/moc . Click on “Coding & RBRVS” on the right side of the page, and then click on “AAP Position Paper on Reporting 99211 with Immunization Administration.” An example of one vignette follows.
The basic premise for billing this level of visit is dependent on one thing—was the purpose of the visit to provide an E/M service of a significant and separate complaint or problem, or was the purpose to perform a procedure? Is it medically necessary, and will the documentation support the medical necessity?
An example of reporting 99211 with vaccine administration is a 4-month-old patient returning for a second hepatitis B vaccine. The vaccine was not given at her well visit 2 weeks earlier because of a high fever at the time of the visit. The nurse documents
The patient is here for a missed hepatitis vaccine and has had no fever for 7 days, is eating again, and seems to be well per father. Past vaccines have been well tolerated. Her temperature now is 98.7°F and she appears well. The risk and potential side effects of the hepatitis vaccine were discussed after the Vaccine Information Statement was given and the parent was informed of the correct dosage of an antipyretic should fever or fussiness occur afterward. The night call system was explained and the access number given.
K. Brooks, LPN/R. Dunn, MD (signatures/date)
This encounter would be reported as follows:
Note that modifier -25 has been appended to the E/M code to reflect that a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service was provided. The use of a separate diagnosis code reported with 99211 also helps support the medical necessity of the visit.
Also note that the reported diagnosis is V67.59. This is correct reporting based on ICD-9-CM guidelines. Many payers, however, will not reimburse an E/M service with this code and will require you to report the “sick” diagnosis (in this case, fever). It is recommended that for these payers, you report the fever followed by V67.59.
Following are other examples for reporting 99211:
A child returns to the office for reading of a PPD administered at the last visit. The nurse documents
Patient here for reading of PPD administered on June 1, 2005. Results indicate 0 mm of induration. Discussed with parents signs/symptoms of disease.
Visit is reported as
An 8-year-old girl returns for weight check and blood pressure (BP) monitoring. The nurse documents
Patient here for weight and BP check. Last seen by Dr Jones 1 month ago. Weight 80 lb; BP 117/78. Doing fairly well with diet. Reviewed diet again with Sarah and Mom, stressed importance of increased exercise. To return for recheck in 1 month.
Note: No matter how much time was spent in counseling during this visit, only 99211 can be reported.
Remember that while most private payers follow CMS coding guidelines, they may establish their own policies for reporting and payment of nurse visits. It is important that every pediatric practice understand specific payer guidelines.
Most health plans will require a co-payment on any E/M service provided. If this is a requirement, you are mandated to collect this co-payment amount for 99211. Education is crucial to help parents understand the value of the service and that is it is a requirement of their health plan.
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Coding Physician Visits in Skilled Nursing Facilities/Nursing Facilities
- Mark Complete
As of April 22, due to the COVID-19 public health emergency , CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options. Prior to this, telehealth was only available for established patient visits.
Coding for Skilled Nursing Facility
- To be reported when the MD, DO, OD visits the patient in the Skilled Nursing Facility.
- Place of Service is 13.
- Initial Visit whether patient is new or established 99304, 99305, 99306
- Subsequent Skilled Nursing Facility visits performed in person or via telehealth: 99307, 99308, 99309, 99310
Coding for Nursing Home Visits
- To be reported when the MD, DO, OD visits the patient in a Nursing Home.
- Place of service is 13
- New Patient: 99324, 99325, 99326, 99327, 99328
- Established Patient: 99334, 99335, 99336, 99337
- Modifier -25
Note: When billing an intravitreal injection (or any minor surgery) the same day as an encounter, consider the definition of modifier -25 and although medically necessary, if the established patient exam is performed solely to confirm the need for the injection, the exam is not separately billable.
Coding for Home Visits
- To be reported when the MD, DO, OD visits the patient at their home.
- Place of service is 12
- New Patient: 99341, 99342, 99343, 99344, 99345
- Established Patient: 99347, 99348, 99349, 99350
View updates on telemedicine coding to use in your practice based on guidelines from CMS.
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MDM indicates medical decision-making.
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Miksanek TJ , Edwards ST , Weyer G , Laiteerapong N. Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits. JAMA Netw Open. 2022;5(8):e2229504. doi:10.1001/jamanetworkopen.2022.29504
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Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits
- 1 Biological Sciences Division, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
- 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
- 4 Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, Illinois
Question 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?
Findings 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.
Meaning 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.
Importance 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.
Objective 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.
Results 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.
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 - 8 After-hours work is especially common for primary care physicians (PCPs) and has frequently been associated with increased rates of burnout. 9 - 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.
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
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.
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.
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 - 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.
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
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 - 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).
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.
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 - 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 - 37 Physicians using these reimbursement systems are unaffected by time-based billing. 38
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.
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 .
Corresponding Author: Neda Laiteerapong, MD, MS, Biological Sciences Division, Department of Medicine, University of Chicago, 5841 S Maryland Ave, MC 2007, Chicago, IL 60637 ( [email protected] ).
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.
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Coding for E/M home visits changed this year. Here’s what you need to know
CPT has revised codes for at-home evaluation and management (E/M) services as of Jan. 1, 2023. Services to patients in a private residence (e.g., house or apartment) or temporary lodgings (e.g., hotel or shelter) are now combined with services in facilities where only minimal health care is provided (e.g., independent or assisted living) in these code families:
Home or residence E/M services, new patient
• 99341, straightforward medical decision making (MDM) or at least 15 minutes total time,
• 99342, low level MDM or at least 30 minutes total time,
• 99344 (code 99343 has been deleted), moderate level MDM or at least 60 minutes total time,
• 99345, high level MDM or at least 75 minutes total time.
Home or residence services, established patient
• 99347, straightforward MDM or at least 20 minutes total time,
• 99348, low level MDM or at least 30 minutes total time,
• 99349, moderate level MDM or at least 40 minutes total time,
• 99350, high level MDM or at least 60 minutes total time.
Select these codes based on either your level of medical decision making or total time on the date of the encounter , similar to selecting codes for office visits . The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in those settings.
When total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. The exception to this is for patients with Medicare. For those patients, report prolonged home or residence services to Medicare with code G0318 in addition to 99345 (requires total time ≥140 minutes) or 99350 (requires total time ≥110 minutes). Code G0318 is not limited to time on the date of the encounter, but includes any work within three days prior to the service or within seven days after.
Services provided in facilities where significant medical or psychiatric care is available (e.g., nursing facility, intermediate care facility for persons with intellectual disabilities, or psychiatric residential treatment facility) are reported with codes 99304-99310 .
— Cindy Hughes, CPC, CFPC
Posted on Jan. 19, 2023
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JAMES M. GIOVINO, MD. Fam Pract Manag. 2000;7 (7):39-42. Level-one" office visits may be the simplest of patient encounters, but when it comes to coding and documentation, they are widely ...
Unlike other E/M codes 99202-99205, and 99212-99215, time alone cannot be used when reporting 99211 when selecting the appropriate code level for E/M services. Effective January 1, 2021, time was removed as an available code-selection criterion. The typical time spent on this code is five minutes. Other visits billed with 99211.
Tip 1: Prove Entire E/M Visit Via Documentation. To report 99211, the clinician must perform an E/M service. In other words, it isn't a catch-all code that you can report every time a patient passes through your practice. Example: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her.
CPT® code 99203: New patient office or other outpatient visit, 30-44 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 ...
The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest. 1, 2 To ease the transition, previous FPM articles have laid out the new ...
Using CPT code 99211 can boost your practice's revenue and improve documentation. The requirements for most evaluation and management (E/M) codes have gotten more precise over the years. However ...
Previously, the code descriptor stated, "Typically, 5 minutes are spent performing or supervising these services.". For dates of service on or after Jan. 1, 2021, you cannot bill 99211 based on time alone, as you can for the rest of the office visit codes. A nurse can document the amount of time spent in the medical record, but you cannot ...
Peter Hollmann, MD Christopher Jagmin, MD Barbara Levy, MD. History of E/M Workgroup. E/M Revisions for 2021: Office and Other Outpatient Services. New Patient (99201-99205) Established Patient (99211-99215) Medical Decision Making (MDM) Time. Prolonged Services.
The Current Procedural Terminology (CPT ®) descriptor for code 99211 states, "Office or other outpatient visit for the evaluation and management [E/M] of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services
2021 Revised E/M Coding Guidelines: 99202-99215. In an effort to reduce burden and improve payment for cognitive care, the American Medical Association along with the Centers for Medicare and Medicaid Services (CMS) have implemented key changes to office and outpatient evaluation and management (E/M) services starting on January 1, 2021.
The patient follows Dr. Smith to "Clinic B." Date of Service. Service Provided. CPT Code. 07/15/23. Established E/M. 99213. Although Dr. Smith is at a different clinic, the patient is still an established patient with him. Dr. Smith's NPI is used to track if the patient has been seen within the previous 3-years.
Six keys to coding 99211 visits. Using CPT code 99211 can boost your practice's revenue and improve documentation. The following guidelines can help you decide whether a service qualifies: 1 ...
Home or residence 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 total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 99345
CPT® code 99212: Established patient office or other outpatient visit, 10-19 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 ...
Prior to this, telehealth was only available for established patient visits. Coding for Skilled Nursing Facility. To be reported when the MD, DO, OD visits the patient in the Skilled Nursing Facility. Place of Service is 13. Initial Visit whether patient is new or established 99304, 99305, 99306
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.
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 ...
and/or descriptors. For this reason, code numbers and/or descriptor language in the CPT code set may differ at the time of publication. CPT® Evaluation and Management (E/M) ... Nursing Facility Services codes 99304-99310, 99315, 99316, Home or ... For example, there are two subcategories of office visits (new patient and established patient ...
Established patient visit New patient visit; Level 2: 99212 10-19 minutes: 99202 15-29 minutes: Level 3: 99213 20-29 minutes: ... According to the 2021 CPT code descriptors, 40-54 minutes ...
Medicare Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners, §30.6.7.A-Definition of New Patient for Selection of E/M Visit Code 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
99328 Domicil/r-home visit new pat 99341 Home visit new patient 99342 Home visit new patient 99343 Home visit new patient 99344 Home visit new patient 99345 Home visit new patient 99406 Behav chng smoking 3-10 min 99407 Behav chng smoking > 10 min 99497 Advncd care plan 30 min G0101 Ca screen; pelvic/breast exam G0102 Prostate ca screening; dre
CR 13568 gives instructions on coding changes and policy updates effective April 1, 2024, for the OPPS. The OPPS changes effective April 1, 2024, are: 1. CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective April 1, 2024. The AMA CPT Editorial Panel established 11 new PLA codes, specifically, CPT codes 0439U-. 0449U.
Initial nursing home visits are coded with 99304-99306. CPT is deleting the code for nursing home annual exams (99318), which will instead be coded as subsequent nursing home visits (99307-99310 ...
Location: Syracuse, New York. Type: Full Time. Categories: Allied Health. Sector: Hospital, Public and Private. Internal Number: 27235. The Cardiology NP performs admissions and discharges on cardiac patients, cardiac catherization, device implantation and ablation. He/she provides patient education and assists in obtaining pre-procedure ...
The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in ...