office visit consult cpt code

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April 3, 2024

Consultation Codes

First, CMS stopped recognizing consult codes in 2010. Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) were still active CPT ® codes, and depending on where you are in the country, are recognized by a payer two, or many payers.

• In 2023, codes 99241 and 99251 are deleted. These two low level consult codes were rarely used. There are four levels of office/outpatient consults and hospital consults. These correspond to the four levels of medical decision making.
• CPT has removed the coding tip –and all language– regarding transfer of care.
• CMS is not planning on changing its policy on consultations.

The advantages to using the consult are codes are twofold: they are not defined as new or established, and may be used for patients the clinician has seen before, if the requirements for a consult are met.”

In this article about consultation codes update:

• Category of code for payers that don’t recognize consult codes
• Definition of a consultation–updated with 2023 CPT guidance
• 2023 documentation changes

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Including updates on CPT ® and CMS coding changes for 2024

Category of code for Medicare and other payers that don’t recognize consult codes

When CMS stopped paying for consults, it said it still recognized the concept of consults, but paid for them using different categories of codes. For an inpatient service, use the initial hospital services codes (99221—99223). If the documentation doesn’t support the lowest level initial hospital care code, use a subsequent hospital care code (99231—99233). Don’t make the mistake of always using subsequent care codes, even if the patient is known to the physician.

For office and outpatient services, use new and established patient visit codes (99202—99215), depending on whether the patient is new or established to the physician, following the CPT rule for new and established patient visits.  Use these codes for consultations for patients in observation as well, because observation is an outpatient service.

For patients seen in the emergency department and sent home, use ED codes (99282—99285).

How will clinicians know if the payer recognizes consults? They won’t know. Most groups suggest that their clinicians continue to select and document consults (when the service is a consult) whether or not they know if the payer recognizes consults or not. They set up an edit in their system so that consult codes can be reviewed and cross walked to the appropriate code, depending on the payer.

Definition of a consultation

When reporting a consultation code follow CPT rules. The statement that I recommend is “I am seeing this patient at the request of Dr. Patel for my evaluation of new onset a-fib.”  At the end of the note, indicate that a copy of the report is being returned to the requesting clinician. In a shared medical record, this can be done electronically.

The requirements for a consultation have not changed.

• There is a request from another healthcare professional or other appropriate source
• An opinion is provided, and
• A report is returned.

From 2023 CPT : “A consultation is a type of evaluation and management service provided at the request of another physician, other qualified health care professional, or appropriate source to recommend care for a specific condition or problem. A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.”

CPT goes on to say that if the consultation is initiated by a patient or family member or other appropriate source, do not use consult codes.  The list of professionals who are “other appropriate sources” according to CPT includes non-clinical social workers, educators, lawyers or insurance companies. However, if your payer still recognizes consults, they will likely require the NPI of a requesting clinician. You likely will not get paid for a consult requested by one of these professionals.

A report is required. “The consultant’s opinion and any other services that were ordered or performed must also be communicated by written report to the requesting physician, other qualified health care professional, or other appropriate source.”

• CPT does not say how the written report is returned: mail, fax, electronic communication.

When you look in your book, notice that CPT has entirely removed the concept of transfer of care . There is no longer a notation that says you cannot bill a consult for a transfer of care.

Consults in 2023 use medical decision making or time

• The AMA has extended the framework for office and outpatient services to consults in 2023. Use either medical decision making or the practitioner’s total time on the date of the visit to select the level of service.

Consulting physician services for hospitalized Medicare patients

What should a consulting physician bill when seeing a hospitalized Medicare patient? An initial hospital service or a subsequent hospital visit?

Medicare stopped recognizing and paying consult codes, but consults are still requested and provided to inpatients every day. The question is, how should they be billed?

If the documentation supports an initial hospital service, use codes 99221-99223, initial hospital care codes.  According to CPT ® , these codes are used for new or established patients. While we think of them and even talk about them as “admission” codes, CPT ® doesn’t use that word.

If the documentation doesn’t have a detailed history and detailed exam, then bill a subsequent hospital visit, rather than the initial hospital care services. But, the correct category of code is initial hospital care. The citation from the Medicare Claims Processing Manual is at the end of this Q&A.

Many commercial insurance companies still recognize consults. Neglecting to bill consults when the carrier pays them results in lost revenue.

Citation from CMS | Inpatient Hospital Services

The CMS Claims Processing Manual, Chapter 12, §30.6.9 F

Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT ® consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians may report a subsequent hospital care CPT ® code for services that were reported as CPT ® consultation codes (99241 – 99255) prior to January 1, 2010, 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. In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT ® consultation code 99251 or 99252. A/B MACs (B) shall not find fault 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.

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Last revised March 15, 2024 - Betsy Nicoletti Tags: office and other E/M

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List With Office Visit CPT Codes (New & Established Patients)

The CPT codes for office visits can be found in the CPT manual; under range CPT 99202 until 99205 for office visits of new patients . For office visits of established patients, you can use range 99211 to CPT code 99215. We also included CPT 99070 in case you need to bill extra supplies/materials for office visits and CPT code 99072 if extra staff and supplies were needed during a Public Health Emergency.

CPT Code 99070

Long description of CPT 99070 : Supplies and materials [except spectacles] provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided].

Short description: Extra supplies/materials for office visit.

CPT Code 99072

Long description of CPT 99072 : Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service[s], when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

Short description: Extra supplies and staff time for office visits during Public Health Emergency.

CPT Code 99202

Long description of CPT 99202 : Office or other outpatient visit for the evaluation and management of a new patient , which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

Short description: 15-29 minute office visit for new patient evaluation and management.

CPT Code 99203

Long description of CPT 99203 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.

Short description: 30-44 minute office visit for new patient evaluation and management.

CPT Code 99204

Long description of CPT 99204 : Office or other outpatient 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 time for code selection, 45-59 minutes of total time is spend on the date of the encounter.

Short description: 45-59 minute office visit for new patient evaluation and management.

CPT Code 99205

Long description of CPT 99205 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code+ selection, 60-74 minutes of total time is spent on the date of the encounter.

Short description: 60-74 minute office visit for new patient evaluation and management.

CPT Code 99211

Long description of 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 or other qualified health care professional

Short description: Short office visit for established patient management.

CPT Code 99212

Long description of CPT Code 99212 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time spent on the date of the encounter.

Short description: 10-19 minute office visit for established patient management.

CPT Code 99213

Long description of CPT 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.

Short description: 20-29 minute office visit for established patient management.

CPT Code 99214

Long description of CPT 99214 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spend on the date of the encounter.

Short description: 30-39 minutes office visit for established patient management.

CPT Code 99215

Long description of CPT 99215 : Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

Short description: 40-54 minutes office visit for established patient management .

https://www.aapc.com/codes/cpt-codes-range/99211-99215/

https://www.aapc.com/codes/cpt-codes-range/99202-99205/

https://www.aapc.com/codes/cpt-codes/99070

https://www.aapc.com/codes/cpt-codes/99072

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Evaluation and management (E/M) services are an essential part of medical practices, especially in family medicine. These services are categorized using Current Procedural Terminology (CPT) codes for billing purposes. Properly documenting and coding for E/M services is crucial to maximize payment and minimize audit-related stress.

There are different levels of E/M codes, determined by the medical decision-making or time involved. It’s worth noting that the guidelines for E/M coding have undergone changes, including the elimination of history and physical exam elements, revisions to the MDM table, and an expanded definition of time for E/M services.

Key Takeaways:

• Understanding E/M codes and guidelines is crucial for accurate billing.
• There are different levels of E/M codes based on medical decision-making or time involved.
• Recent changes to E/M coding include the elimination of history and physical exam elements.
• The definition of time for E/M services has been expanded.
• Proper documentation and coding help maximize payment and reduce audit-related stress.

Overview of Office Visit CPT Code Changes

The CPT Editorial Panel made significant revisions to the documentation and coding guidelines for office visit E/M services in 2021, with further changes introduced in 2023. These updates aim to simplify documentation requirements, reduce administrative burden, and ensure accurate coding for evaluation and management services.

One of the key changes introduced is the addition of add-on code G2211. This code accounts for the resource costs associated with visit complexity inherent to primary care and other longitudinal care settings. The inclusion of this add-on code reflects a more comprehensive understanding of the unique challenges and workload associated with these types of visits.

Additionally, the revisions eliminate the requirement for history and physical exam elements to be considered in E/M code level selection. This change allows healthcare providers to focus more on medical decision-making (MDM) and limits the need for extensive documentation of these elements in the medical record.

The MDM table has also been revised to better reflect the cognitive work required for evaluation and management services. This ensures that the complexity of the MDM is accurately captured in the coding process and supports appropriate reimbursement for the level of care provided.

Furthermore, the definition of time for many E/M services has been expanded. The expanded definition of time includes both face-to-face and non-face-to-face components of care on the day of the encounter. This change recognizes the comprehensive nature of care provided and allows for a more accurate reflection of the time spent in the management of the patient.

Using Total Time for Office Visit CPT Code Selection

When it comes to selecting the appropriate office visit CPT code, total time can be a valuable factor to consider. Total time refers to the sum of all the physician’s or qualified health professional’s (QHP) time spent in caring for the patient, both face-to-face and non-face-to-face, on the day of the encounter. This expanded definition of time allows for a more comprehensive evaluation and management of the patient’s needs.

Total time can be utilized in selecting the level of service for various evaluation and management services, including office visits, inpatient and observation care, consultations, nursing facility services, home and residence services, and prolonged services. It provides a broader perspective on the physician’s involvement in the patient’s care, taking into account all aspects of their interaction.

However, it’s important to note that for emergency department visits, the level of service is still determined primarily by medical decision-making (MDM), rather than total time. This distinction recognizes the critical nature of emergency care and the need for prompt assessment and action.

Accurate documentation of the total time spent is key to ensuring proper code selection and appropriate reimbursement. The total time should be well-documented in the patient’s medical record, including both the face-to-face and non-face-to-face components of the encounter. This documentation serves as a crucial reference point for billing and auditing purposes.

To summarize, total time offers a comprehensive perspective on the physician’s engagement with the patient, encompassing both face-to-face and non-face-to-face interactions. It allows for a more accurate selection of office visit CPT codes and ensures the appropriate level of reimbursement for the provided services. Proper documentation of total time is essential to support the medical necessity of the encounter and maintain compliance with coding and billing guidelines.

Documentation Requirements for Total Time Calculation

When determining the total time for selecting office visit CPT codes, it is essential to adhere to specific documentation requirements. By accurately documenting the time spent on various activities during the encounter, healthcare providers can ensure proper code selection and optimize reimbursement.

To calculate the total time for office visit code selection, the following activities should be included:

• Reviewing external notes/tests
• Performing an examination
• Counseling and educating the patient
• Documenting in the medical record

These activities reflect the time personally spent by the physician or qualified health professional (QHP) on the date of the encounter. However, there are also activities that should be excluded when calculating total time:

• Time spent on activities typically performed by ancillary staff
• Time related to separately reportable activities

It is crucial to specifically document the total time spent on each activity during the date of the encounter, rather than providing generic time ranges. This detailed documentation ensures transparency and accuracy in code selection and reimbursement.

In addition to capturing face-to-face time, it is important to record non-face-to-face time as well. Non-face-to-face time includes tasks performed outside of direct interaction with the patient, such as reviewing test results or consulting with other healthcare professionals.

Example of Total Time Calculation:

Let’s consider an example where a family physician spends the following time on a patient encounter:

• 45 minutes performing an examination and counseling
• 15 minutes reviewing external notes/tests
• 10 minutes documenting in the medical record
• 5 minutes discussing with an ancillary staff

In this case, the total time would be calculated as follows:

By accurately documenting the specific total time spent on each activity and excluding ancillary staff time, healthcare providers can ensure proper code selection and reimbursement. This meticulous documentation of total time in the medical record provides a comprehensive overview of the services rendered and supports accurate billing.

Split or Shared Visit Documentation Guidelines

A split or shared visit occurs when a physician and other qualified health professional (QHP) provide care to a patient together during a single Evaluation and Management (E/M) service. In such cases, the time personally spent by the physician and QHP on the date of the encounter should be summed to define the total time.

However, only distinct time should be counted. This means that overlapping time during jointly meeting with or discussing the patient should not be double-counted. The distinct time should represent the unique contribution of each provider involved in the split or shared visit.

It is important to note that time spent on activities performed by ancillary staff should not be included in the total time calculations. The total time should only reflect the face-to-face time and distinct time spent by the physician and other QHP directly involved in providing the medically necessary services.

Documentation should support the medical necessity of both services reported in a split or shared visit scenario. This includes clearly documenting the need for both physicians or QHPs to be involved and the services each provider contributed to the patient’s care.

Applying Total Time to Specific E/M Services

Total time is a valuable tool for selecting the appropriate level of service for a variety of Evaluation and Management (E/M) services. This method can be applied to different specific E/M services, ensuring that the level of care is clinically appropriate and adequately reimbursed. By considering the total time spent during the encounter, healthcare providers can accurately assign the appropriate office visit CPT code.

The application of total time is not limited to office visit services. It can also be used for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services. This flexibility allows for a comprehensive approach to E/M coding, regardless of the specific type of service provided.

When selecting the visit level based on total time, it is important to ensure that the encounter is counseling-dominated. While total time can be used as the sole determinant for selecting the visit level, counseling should still play a significant role in the encounter. This ensures that the level of service reflects the complexity and intensity of the counseling provided during the visit.

It is crucial to emphasize that total time should be clinically appropriate and supported by documentation in the medical record. This documentation should clearly demonstrate the medical necessity of the services provided and the time spent on the date of the encounter.

Applying Total Time to E/M Services: An Example

To illustrate the application of total time to specific E/M services, let’s consider an example of an office visit for a counseling-dominated encounter:

In this example, the total time spent during the encounter determines the appropriate level of visit code. For a total time of 25 minutes, a level 3 visit (CPT code 99213) is selected. If the total time is 40 minutes, a level 4 visit (CPT code 99214) would be appropriate. Finally, a total time of 60 minutes would result in a level 5 visit (CPT code 99215).

By applying total time to specific E/M services, healthcare providers can ensure accurate coding and appropriate reimbursement for the care provided. This method promotes comprehensive and patient-centered care while maintaining compliance with coding guidelines. Understanding the nuances of applying total time is essential for optimizing billing practices and promoting quality healthcare delivery.

Caveats and Considerations for Time-based E/M Coding

When utilizing time as the basis for selecting E/M codes, there are important caveats and considerations to keep in mind. Time-based coding should only be used in situations where counseling dominates the encounter, and it should not include time spent on separately reportable services. Documentation should clearly indicate that the services provided were not duplicative and were necessary for the management of the patient. Additionally, it is crucial to note that the professional component of diagnostic tests/studies and activities performed on a separate date should not be included in the total time calculation.

Considerations for Time-based E/M Coding

• Use time-based coding only when counseling dominates the encounter.
• Exclude time spent on separately reportable services.
• Ensure documentation supports the necessity of the provided services.
• Do not include the professional component of diagnostic tests/studies.

Implications of Time-based E/M Coding

When selecting E/M codes based on time, it is important to adhere to the specified guidelines and considerations. Failing to do so can lead to inaccurate coding, reimbursement issues, and potential compliance concerns. By understanding the requirements and accurately documenting the relevant information, healthcare providers can ensure proper medical billing and maintain compliance with coding and documentation guidelines.

Documentation Requirements for Time-based E/M Coding

Updates and Changes to CPT E/M Guidelines

The CPT Editorial Panel has recently implemented updates and changes to the Evaluation and Management (E/M) guidelines, specifically focusing on medical decision making (MDM), history, and exam. These updates aim to enhance the accuracy and specificity of E/M coding and documentation.

One significant change in the new guidelines is the emphasis on a medically appropriate history or exam, rather than relying solely on the number or complexity of problems addressed. This shift highlights the importance of gathering comprehensive patient information to guide medical decision making.

The MDM levels have also been revised to align with those used for office visits. This alignment ensures consistency across different types of E/M services and facilitates accurate code selection for medical billing and reimbursement.

By updating and refining the guidelines, the CPT Editorial Panel aims to streamline the coding and documentation process, making it easier for healthcare providers to accurately capture the complexity of patient encounters and facilitate proper reimbursement.

Changes in CPT E/M Guidelines

| Old Guidelines | Updated Guidelines | |—————————-|———————————| | Emphasized number of | Emphasize medically appropriate | | problems addressed | history or exam | | MDM levels differed across | MDM levels align with office | | different E/M services | visit levels | | | |

The updates in the CPT E/M guidelines bring about significant changes in capturing the complexity of patient encounters. Healthcare providers should familiarize themselves with these updates to ensure compliance with the revised guidelines, thereby facilitating accurate coding, billing, and reimbursement.

Guidelines for MDM Selection in E/M Services

In the process of selecting the appropriate E/M codes for evaluation and management (E/M) services, medical decision making (MDM) plays a crucial role. MDM encompasses several factors that need to be considered, including the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

It is important to note that the final diagnosis alone does not determine the complexity of MDM. Rather, the complexity is determined by the impact of the condition on the management of the patient. The more complex the problems, comorbidities, and data analysis, as well as the higher the risk of complications, morbidity, or mortality, the more intricate the MDM.

In accurately reflecting the level of complexity in the documentation and coding of E/M services, healthcare providers ensure proper reimbursement and compliance with coding guidelines. By carefully evaluating the factors that contribute to MDM, providers can effectively demonstrate the complexity of the problems addressed and the resources required to manage them.

Here is a breakdown of the key considerations for MDM selection in E/M services:

• Number and complexity of problems addressed
• Comorbidities
• Amount and complexity of data reviewed and analyzed
• Risk of complications, morbidity, or mortality
• Final diagnosis and its impact on management
• Complexity of problems and their management

Accurately documenting and coding the appropriate level of MDM is essential for ensuring proper reimbursement and comprehensive representation of the complexity of the patient’s condition. It is crucial to pay attention to the specifics of each patient’s case and make informed decisions based on thorough evaluation and analysis.

Impact of Office Visit CPT Code Changes on Medical Billing

The changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. Healthcare providers must adapt to these changes and understand the documentation requirements and accurate coding necessary to ensure proper reimbursement and reduce the risk of audits.

Accurate coding is crucial in accurately reflecting the level of service provided during the office visit. It ensures that healthcare providers receive accurate reimbursement for their services and helps to reduce the burden of potential audits. Proper documentation and coding also contribute to compliance with coding and documentation requirements, mitigating the risk of financial loss and noncompliance.

It is essential for healthcare providers to familiarize themselves with the new guidelines and understand how to properly document the relevant information. This includes accurately capturing the level of service provided, the complexity of problems addressed, and the time spent on the date of the encounter. By adhering to these documentation requirements, healthcare providers can ensure accurate coding and reimbursement, reducing the risk of claims denials or audits.

Proper documentation not only helps in accurate coding and reimbursement but also simplifies auditing processes, ensuring compliance with coding and documentation requirements. Auditing plays a vital role in the healthcare system, and having the appropriate documentation in place can streamline the auditing process and provide evidence of accurate and compliant billing practices.

Compliance with coding and documentation requirements is essential to avoid potential financial loss and maintain a good standing within the healthcare industry. By accurately documenting and coding office visit services, healthcare providers can demonstrate their commitment to compliance and ensure that they are providing high-quality care to their patients.

In conclusion, the changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. It is crucial for healthcare providers to understand the documentation requirements, accurately code the services provided, and ensure compliance with coding and documentation guidelines. By doing so, healthcare providers can streamline the billing process, reduce the risk of audits, and ensure accurate reimbursement for their services.

Resources for Understanding Office Visit CPT Code Guidelines

When it comes to understanding the guidelines for office visit CPT codes and navigating the changes in E/M coding, healthcare providers can rely on valuable resources provided by reputable organizations such as the American Medical Association (AMA) and the Medicare Learning Network (MLN). These resources offer comprehensive guidance and tools that can help healthcare providers stay up to date and ensure accurate reimbursement.

The CPT Evaluation and Management Services Guidelines, developed by the AMA, provide detailed information on office visit CPT codes, E/M coding principles, and documentation requirements. This resource serves as a comprehensive guide to help healthcare providers understand the intricacies of office visit coding and ensure compliance with the latest guidelines.

The Medicare Learning Network, an educational resource developed by the Centers for Medicare & Medicaid Services (CMS), offers webinars, articles, and other educational materials specifically designed to assist healthcare providers in understanding and implementing the changes in E/M coding. These resources provide practical insights and clarification on the documentation requirements and coding changes specific to office visit CPT codes.

Furthermore, the Medicare Physician Fee Schedule Lookup Tool, available on the CMS website, enables healthcare providers to access reimbursement information for specific office visit CPT codes. This tool allows providers to accurately determine the appropriate reimbursement for their services and ensure proper billing practices.

By leveraging these resources, healthcare providers can enhance their understanding of office visit CPT code guidelines, navigate the complexities of E/M coding, and ensure accurate reimbursement for their services. Staying informed and utilizing these valuable resources is imperative for maintaining compliance and optimizing coding practices.

Understanding the guidelines for office visit CPT codes is essential for accurate medical billing and insurance reimbursement. The recent changes in E/M coding guidelines, particularly regarding time-based code selection and medical decision making, necessitate proper documentation and accurate coding. By comprehensively understanding these guidelines, healthcare providers can maximize their payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

Accurate medical billing is crucial for healthcare practices to receive fair reimbursement from insurance companies. By following the comprehensive guide provided by the American Medical Association (AMA) and the Medicare Learning Network (MLN), healthcare providers can confidently navigate the complexities of office visit CPT codes. This comprehensive guide provides detailed information on selecting the appropriate codes based on medical decision making, time-based code selection, and documentation requirements.

Properly documenting the relevant information and coding accurately not only ensures accurate reimbursement but also reduces the risk of audits and increases compliance. By adhering to the guidelines and best practices outlined in the comprehensive guide, healthcare providers can maintain accurate and compliant medical billing practices, ultimately benefiting both their practice and their patients.

In conclusion, understanding the guidelines for office visit CPT codes is crucial for accurate medical billing and insurance reimbursement. By following the comprehensive guide provided by industry resources such as the AMA and MLN, healthcare providers can navigate the changes in E/M coding and ensure compliance with coding and documentation requirements. This comprehensive understanding of the guidelines allows healthcare providers to optimize payment, minimize audit-related stress, and maintain accurate and compliant medical billing practices.

What are office visit CPT codes?

Office visit CPT codes are evaluation and management (E/M) codes used for billing purposes in family medicine practices and other healthcare settings.

What are the changes to the office visit CPT code guidelines?

The office visit CPT code guidelines have been revised to eliminate the history and physical exam elements, introduce an add-on code for visit complexity, revise the medical decision-making table, and expand the definition of time for E/M services.

How can total time be used for office visit CPT code selection?

Total time, which includes both face-to-face and non-face-to-face interactions, can be used to select the level of service for office visit codes and other E/M services.

What should be included in the calculation of total time for office visit code selection?

Activities such as examining the patient, counseling and educating the patient, reviewing external notes/tests, and documenting in the medical record should be included in the calculation of total time. Ancillary staff time and time related to separately reportable activities should be excluded.

How should total time be documented for office visit code selection?

It is important to document the specific total time spent on activities on the date of the encounter in the patient’s medical record, rather than providing generic time ranges.

What are the documentation guidelines for split or shared visits?

In a split or shared visit scenario, the time personally spent by the physician and other qualified health professional (QHP) should be summed to define total time. Distinct time should be counted, and time spent on activities performed by ancillary staff should not be included.

Can total time be used for other E/M services besides office visits?

Yes, total time can be used to select the level of service for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services.

What are the caveats and considerations for time-based E/M coding?

Time-based coding should only be used when counseling dominates the encounter, and it should not include time spent on separately reportable services. It is important to ensure that the services provided were necessary for the management of the patient.

What updates have been made to the CPT E/M guidelines?

The CPT E/M guidelines have been updated to emphasize the need for a medically appropriate history or exam and to revise the levels of medical decision making to align with office visit levels.

How is medical decision making (MDM) determined in E/M services?

MDM is determined by considering the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

What is the impact of the office visit CPT code changes on medical billing?

The changes in office visit CPT code guidelines have a significant impact on medical billing, requiring proper documentation and accurate coding to ensure accurate reimbursement and reduce the risk of audits.

Where can healthcare providers find resources to understand the office visit CPT code guidelines?

Healthcare providers can refer to resources such as the CPT Evaluation and Management Services Guidelines from the American Medical Association and the Medicare Learning Network for guidance on understanding and implementing the office visit CPT code guidelines.

What is the importance of understanding office visit CPT code guidelines?

Understanding office visit CPT code guidelines is crucial for accurate medical billing, insurance reimbursement, and compliance with coding and documentation requirements.

What is the overall purpose of the comprehensive guide on office visit CPT code guidelines?

The comprehensive guide on office visit CPT code guidelines provides healthcare providers with a thorough understanding of the guidelines, enabling them to maximize payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

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Coding FAQ: Patient office visits

Question: How do I code for a patient office visit? Can I use consultation codes? What diagnosis code is appropriate for a patient office visit during which the patient is evaluated for OSA and scheduled for testing?

Answer: Patient visits are billed using evaluation and management (E/M) codes. The E/M codes are found in the CPT® code book. Office visits in particular are billed using two code ranges – for new patients, E/M codes 99201-99205 can be used; for established patients, E/M codes 99211-99215 can be used. Medicare no longer reimburses for consultation codes (E/M code range 99241-99245). However, some private payers may still reimburse for these services. Physicians should bill diagnosis code(s) that justify the service. In the case of an office visit, this may include hypersomnolence, snoring, obesity, or a range of complicating comorbidities such as hypertension. Unless the patient has been diagnosed with obstructive sleep apnea (OSA) previously, the diagnosis of OSA can’t be assigned until testing and interpretation is complete.

These recommendations may change, however, given the CMS Proposed Rule , in which CMS outlined plans to significantly modify E/M documentation guidelines, coding, and reimbursement, to align with the Patients over Paperwork initiative.  The AASM expressed support for the American Medical Association’s response to CMS , which encouraged the Agency to allow the medical community to assist with revising the E/M process through the formation of a workgroup, made up of health care professionals with experience in coding, reimbursement, and clinical expertise.  The Workgroup has since been convened and is working to identify solutions to the current E/M coding and payment issues and provide solutions for implementation in the 2020 calendar year.

If the coding recommendations change, an updated response to this coding question will be featured and posted to the AASM website.

In the meantime, please send any questions to [email protected] . Read more  Coding FAQs .

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Office Visit or Consultation? Here’s How to Make the Call

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This article is from June 2006 and may contain outdated material.

When can you code for a consultation? According to the latest CMS guidance, Medicare won’t pay for a reasonable and medically necessary consultation unless you meet these three requirements:

• The service is provided by a physician or qualified nonphysician practitioner (NPP) 1 whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. This requirement distinguishes a consultation service from other E&M visits.
• The consultant documents both a request for a consultation from an appropriate source and the need for consultation (i.e., the reason for the service) in the patient’s medical record. This also must appear in the requesting physician’s or qualified NPP’s plan of care, which is in the patient’s medical record.
• The consultant provides a written report of his or her findings and recommendations, which shall be provided to the referring physician. If, say, a large multispecialty group practice uses a shared medical record, it would be enough to include the consultant’s report in the medical record documentation rather than requiring a separate letter from the consultant. Those findings and recommendations should be available in the consultation report.

What expertise is required? The intent of a consultation is that a referring professional is asking the consultant for help (e.g., an opinion or direction) in evaluating or treating a patient because that consultant has expertise in a specific medical area beyond the requesting professional’s knowledge.

Will you get paid for intraoffice consultations? Provided that the expertise requirement is met, Medicare will pay for a consultation even when the requesting professional and the consultant are both in the same group practice. However, a consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting.

When can care be initiated? A physician or qualified NPP may initiate diagnostic services and treatment at the initial consultation service.

Definitely Not a Consult

The following do not meet the criteria for consultation services: Standing orders in the medical record; no order for a consultation; and no written report of a consultation.

Transfer of care. When a physician or qualified NPP asks another physician or qualified NPP to take over responsibility for managing the patient’s complete care, it is considered a transfer of care. Coding should be for the appropriate level of new or established E&M code or Eye Code, but not a consultation code.

CMS provides this example. An ER physician treats a patient for a sprained ankle. The patient is discharged and told to visit the orthopedic clinic for follow-up. Since the ER physician doesn’t need any advice or opinion from the clinic’s physician, the clinic can’t report a consultation service but should report the appropriate office or other outpatient visit code instead.

_________________________________

1 Medicare defines an NPP as “any nonphysician licensed medical professional.” It includes in this definition providers such as physician assistants, nurse practitioners and clinical nurse specialists, as well as social workers, physical therapists and speech therapists.

For the latest coding updates, visit www.aao.org/aaoe .

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Determining whether the visit you've just finished should be coded as a level 4 could be as simple as asking yourself three questions.

KEITH W. MILLETTE, MD, FAAFP, RPH

Fam Pract Manag. 2021;28(1):27-33

Author disclosure: no relevant financial affiliations disclosed.

Performing level 4 evaluation and management (E/M) outpatient visits but coding them as level 3 visits is a costly mistake for family physicians. It can result in $30,000 or more in lost revenue in a year, depending on practice volume. Some doctors choose to report a level 3 instead of a level 4 because of fear of over-coding. 1 Some do level 4 work but their documentation is lacking and doesn't support a level 4 code. But the most common reason I've seen for under-coding level 4 visits is that the coding criteria are complex and time-consuming.

“Coding is complicated and boring,” I often hear physicians say. “I have better things to do, like take care of my patients.”

New rules for coding and documenting outpatient E/M office visits should simplify things, clear up confusion, and help you code more confidently and accurately.

The rules, which took effect Jan. 1, are the most significant changes to E/M coding since 1997 (for more details, see “ Countdown to the E/M Coding Changes ” in the September/October 2020 issue of FPM ). Coding for outpatient E/M office visits is now based solely on either the level of medical decision making (MDM) required or the total time you spend on the visit on the date of service. (See “ E/M coding changes series .”) The history and exam components are no longer used for coding purposes. (Note: these changes apply only to regular office visits and not to nursing home or hospital E/M visits.)

The 2021 E/M coding changes should help ensure you're not leaving money on the table, especially when it comes to coding level 4 visits, which is not as straightforward as coding other levels.

Doing level 4 evaluation and management (E/M) work but coding it as a level 3 office visit is a common mistake that can cost a family physician thousands of dollars each year.

Rule changes that eliminated the history and exam portions from coding requirements should make it easier to identify level 4 office visits and code them for appropriate reimbursement.

Answering three basic questions can help you identify whether you've performed a level 4 visit.

E/M CODING CHANGES SERIES

September/October 2020 — Countdown to the E/M Coding Changes

November/December 2020 — The 2021 Office Visit Coding Changes: Putting the Pieces Together

January/February 2021 — Coding Level 4 Office Visits Using the New E/M Guidelines

CODING LEVEL 4 VISITS: THE BASICS

These are the basic parameters for coding a level 4 visit based on total time or MDM under the new rules.

Total time includes all time the physician or other qualified health professional (QHP) spends on that patient on the day of the encounter. This includes time spent reviewing the patient's chart before the visit, face-to-face time during the visit, and time spent after the visit documenting the encounter. It may also include discussing the patient's care with other health professionals or family members, calling the patient later in the day, or ordering medications, studies, procedures, or referrals, as long as those actions happen before midnight on the date of service. Total time does not include time spent performing separately billed procedures or time spent by your nurse or other office staff caring for the patient.

The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30–39 minutes. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45–59 minutes.

Many EHRs have time calculators that will show the amount of time you have had the patient's chart open. This will help you keep track of time while you're reviewing the chart before the visit, performing the exam (if you always open the chart at the beginning of the visit and close it at the end of the encounter), and making notes after the visit. It will be less helpful for physicians who open the computer only when needed during the patient visit.

Documentation of total time is fairly straightforward: just note how much time you spent on the visit that day. You aren't required to break down how much time you spent before, during, and after the visit, though that may be helpful supportive detail in the event of an audit. You may want to include a short definition of total time so that patients who read their notes don't confuse it with face-to-face time and think, “My doctor only spent 20 minutes with me, not the 40 minutes listed here.” For example, your documentation could say, “Total time: 40 minutes. This includes time spent with the patient during the visit as well as time spent before and after the visit reviewing the chart, documenting the encounter, making phone calls, reviewing studies, etc.” In addition to preventing misunderstandings, this gives patients a better idea of all the time we spend on them outside of the actual visit. Another way to accomplish it without “note bloat” is to have a pop-up message with this information that appears in the EHR whenever patients access their notes.

Medical decision making is still made up of three elements: problems, data, and risk. But the definitions have changed somewhat (see “ CPT E/M office revisions: level of medical decision making ”). The overall level of the visit is determined by the highest levels met in at least two of those three elements. That means that for an outpatient E/M office visit to be coded as a level 4 (for new or established patients), you need at least two of the three elements to reach the “moderate” category — moderate number and complexity of problems addressed; moderate amount and/or complexity of data to be reviewed and analyzed; or moderate risk of complications and/or morbidity or mortality of patient management. An important difference between coding based on MDM versus total time is that you may count MDM that occurs outside of the date of service (e.g., data reviewed or ordered the day after the patient's visit).

To make this simpler, let's substitute “level 4” for the term “moderate” as we take a look at what qualifies in each category (problems, data, and risk).

Level 4 problems include the following:

One unstable chronic illness (for coding purposes “unstable” includes hypertension in patients whose blood pressure is not at goal or diabetes in patients whose A1C is not at goal),

Two stable chronic illnesses (e.g., controlled hypertension, diabetes, chronic kidney disease, or heart disease),

One acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia),

One acute complicated injury (e.g., concussion),

One new problem with uncertain prognosis (e.g., breast lump).

Level 4 data includes the following:

One x-ray or electrocardiogram (ECG) interpreted by you,

Discussion of the patient's management or test results with an external physician (one from a different medical group or different specialty/subspecialty),

A total of three points, earned as follows: a) One point for each unique test ordered or reviewed (panels count as one point each; you cannot count labs you order and perform in-office yourself), b) One point for reviewing note(s) from each external source, and c) One point for using an independent historian.

Level 4 risk includes the following:

Prescription drug management, which includes ordering, changing, stopping, refilling, or deciding to continue a prescription medication (as long as the physician documents evaluation of the condition for which the medication is being managed),

The presence of social determinants of health (lack of money, food, or housing) that significantly limit a patient's diagnosis or treatment,

Decision about major elective surgery without identified risk factors for patient or procedure,

Decision about minor surgery with identified risk factors for patient or procedure.

IDENTIFYING LEVEL 4 VISITS IN THREE QUESTIONS

Here are three questions you can ask yourself to quickly determine whether you've just performed a level 4 visit:

Was your total time between 30 and 39 minutes for an established patient, or between 45 and 59 minutes for a new patient? If so, then you're done. Code it as a level 4 using total time.

Did you see the patient for a level 4 problem and either order/review level 4 data or manage level 4 risk? If so, then code it as a level 4 using MDM.

Did you order/review level 4 data and manage level 4 risk? If so, code it as a level 4 using MDM.

Another way to simplify coding level 4 visits is to recognize that ordering labs, x-rays, ECGs, and medications (prescription drug management) often signals level 4 work, while using independent historians, discussing care/studies with external physicians, and providing care limited by social determinants of health are not used as often to code level 4 visits. Therefore, questions 2 and 3 could be rephrased or shortened as follows:

2. Did you see the patient for a level 4 problem and either prescribe a medication, interpret an x-ray (or ECG), or order/review three tests?

3. Did you prescribe a medication and either interpret an x-ray (or ECG) or order/review three tests?

OFFICE VISIT EXAMPLES

Now let's look at three examples of level 4 office visits, documented with the usual SOAP (subjective, objective, assessment, and plan) note. See if you can identify why each is a level 4 before you get to the explanation.

Subjective: 44 yo female presents with 3 day hx of dysuria, frequency, urgency, L mid back pain, fever, chills, and nausea. Has prior hx of UTIs. No hx of pyelo. No hx of resistant infections. Able to keep food down .

Objective: T 100.2, P 96, R 18, BP 110/70. Pt looks ill but not toxic .

EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: Benign. NECK: Benign. No cervical adenopathy. HEART: S1 and S2 w/o murmurs. LUNGS: Clear. Breathing is nonlabored. ABDOMEN: soft, nontender, moderate L CVA tenderness. EXTREMITIES no edema .

Laboratory: UA – TNTC, WBCs – 4+ bacteria .

Assessment/Plan: Pyelonephritis N12. Discussed acute pyelo, also ways to prevent bladder infections. Handout given. Push fluids. Discussed fever and pain control. Cipro 500 mg po bid x 7 days with appropriate precautions. RTC 72 hours, RTC or ER sooner if red flags occur .

Explanation: The total time for this visit was 25 minutes (in the range of a level 3 visit), so it can't be coded as a level 4 using total time. The time also was not documented in the note, which would be required to support coding based on total time. However, here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: acute illness with systemic symptoms.

Was level 4 data ordered/reviewed? No: two lab tests reviewed (three are required).

Was level 4 risk managed? Yes: prescription drug management.

Two out of three criteria meet the requirements for a level 4, so code it as a level 4.

Subjective: 23 y/o female presents for recheck of depression, also complaining of sore throat and ankle sprain .

Counseling going well. Started on sertraline 50 mg 4 months ago. No new stressors. Pt denies depressed mood, insomnia, anorexia, loss of pleasure, suicidal ideation, poor concentration, or irritability. Anxiety is also well controlled .

Has 2 day hx of L lateral ankle pain. Tripped over dog and turned ankle in. Pt able to walk now with mild limp .

Has a 3 day hx of sore throat, fever, and fatigue. Denies other symptoms .

Objective: T 100.4, P 88, R 14, BP 125/70. Pt is NAD, affect is bright, eye contact is good. EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: tonsils 2+ red s exudate. NECK: Benign. No cervical adenopathy. HEART: RRR. LUNGS: Clear. Bilateral ankle exam: L ant drawer is negative, inversion testing on L causes pain, focal mild tenderness and swelling just below L lat malleolus .

Laboratory: strep screen – negative, strep culture – pending .

Assessment/Plan: Depression with anxiety F41.8 well controlled. Sertraline 50 mg refilled. Continue counseling. Discussed depression .

Tonsillitis J03.90. Strep screen neg. Discussed symptomatic measures. Will call if strep culture is positive .

Sprain left ankle, initial encounter S93.492A, is mild and improving. Discussed RICE protocol and NSAIDS if needed .

RTC 2 mo to recheck depression. Call or RTC sooner if problems or concerns develop .

Total time: 35 minutes. This includes time spent with the patient, but also time spent before the visit reviewing the chart and time after the visit documenting the visit, etc .

Explanation: The total time for this visit (35 minutes) is in the range of a level 4 (30–39 minutes), so a physician could code it as a level 4 using total time. However, here's the breakdown for MDM:

Was there a level 4 problem? No: One stable chronic illness, one acute uncomplicated illness, and one acute uncomplicated injury.

Was level 4 data ordered/reviewed? No: two lab tests.

This visit only meets one out of three criteria, so it can't be coded as a level 4 based on MDM. But because the physician has documented that the visit met the criteria for a level 4 based on total time, it can be coded as a level 4.

Subjective: 47 y/o male presents for a BP recheck. His home blood pressures have been averaging 155/95. He denies chest pain, fast heart rate, headache, flushing, or nose-bleeds. Feels good. Taking losartan every day. Watches his wt and exercises .

Objective: T 97.2, P 72, R 16, BP 160/95. NAD.

EYES: Fundi nl. PERRLA. TMs: nl .

PHARYNX: nl. NECK: Benign. Thyroid is not enlarged. HEART: S1 and S2 no murmurs. LUNGS: Clear. ABDOMEN: No masses or organomegaly. EXTREMITIES: no edema .

Assessment/Plan: Essential hypertension I10. Increase losartan to 100 mg per day. Check BP 3 times a wk, avoid salt, continue to limit alcohol to 2 drinks a day or less. RTC for BP check in 3 wks, sooner if problems arise .

Explanation: Total time for this visit was 20 minutes (but not documented in note). That is in the range of a level 3 visit, not a level 4.

Here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: One chronic, uncontrolled illness.

Was level 4 data reviewed/ordered? No: No tests were ordered.

Was level 4 risk managed? Yes: Prescription drug management.

Two out of three criteria were met, so code it as a level 4.

(Templates to help code visits based on total time or MDM are available with “ Countdown to the E/M Coding Changes ,” FPM September/October 2020.)

HOW DOES YOUR LEVEL 4 CODING COMPARE?

Comparing your coding with national averages is a good way to gauge where you stand in terms of getting the reimbursements you deserve. The national average for family physicians' usage of the level 4 code (99214) is slowly increasing and is approaching 50% of established patient office visits (it's now above 50% for our Medicare patients). 2

That's a good benchmark. But all practices are different, and some coding variation is normal. In general, doctors with more elderly patients usually have a higher percentage of level 4 visits. Doctors who address fewer problems per visit, have a high patient volume, or have a younger panel tend to have a lower percentage of level 4 visits.

Coding should be easier with the removal of the history and exam components, allowing us to focus more on treating our patients. By using the three questions presented in this article, as well as the patient examples, you should be able to more confidently code level 4 visits and make sure you're getting paid for the amount of work you're doing.

Hill E. How to get all the 99214s you deserve. Fam Pract Manag . 2003;10(9):31-36.

Marting R. 99213 or 99214? Three tips for navigating the coding conundrum. Fam Pract Manag . 2018;25(4):5-10.

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