Routine Office Visits for acute or chronic care is sometimes known as “episodic care” or “fee-for-service” (FFS). The E/M codes include 99202-99205 for New patients, and 99211-99215 for Established patients. There are two ways to decide on the particular billing level: Medical Decision-Making (MDM) or Time-Based Coding.
Be aware that some patients may be required to pay a copay for their office visits, and may also pay whatever portion of the visit that health insurance doesn't cover. For patients with no insurance, it’s important to be aware of how much the visit costs “out of pocket.” You may also want to know if there are payment plans and/or charity discounts.
Medical Decision-Making
Many outpatient E/M codes are now determined by documentation of medical decision-making (MDM) (except for time-based coding). There are no longer any specific documentation requirements for the History and Physical Exam so documentation should simply be supportive of what is needed medically and medico-legally. Coding by medical decision-making is identical for New patients and Established patients, as we review below.
There are three areas that affect the medical complexity of the visit:
1. Number and Complexity of Problems or Diagnoses
2. Amount and/or Complexity of Data to be Reviewed and Analyzed
3. Risk of Complications and/or Morbidity of Patient
These three areas are categorized as minimal, limited/low, moderate, or extensive/high complexity. The determination of Risk is perhaps the most subjective. Data reviewed can include laboratory studies, radiology, EKG, PFTs, reviewing documents (by specialists or outside providers), discussion with other healthcare professionals or family members, and ordering tests. Each unique test, order, or document receives a data point to meet a threshold number.
There are a couple of caveats:
1. You get a data point towards MDM for either ordering a test or reviewing it, but you can’t count the same test twice for both ordering it and reviewing the same test (previously completed).
2. If your practice is billing for a test you ordered, e.g., a point-of-care test or an ECG done in the office (where your clinic bills for both doing the ECG and for interpretation), then it's not advised to “double-dip” by counting a data point for ordering that test in your MDM. However, if your practice isn’t billing for the interpretation of that same ECG then you can count 1 point for personally reviewing the ECG. In other words, you only count tests once for billing. Point-of-care tests shouldn’t be used for MDM, but the test itself is billed.
|
Code
|
Level of MDM
(Based on 2 out of 3 Elements)
|
Number and complexity of problems or diagnoses
|
Amount and/or complexity of data to be reviewed
|
Risk of complications and/or morbidity/
mortality with/without further testing or treatment
|
|
99211*
(Nurse visit)
|
N/A
|
N/A
|
N/A
|
N/A
|
|
99202
99212
|
Straight-
forward
|
Minimal
• 1 self-limited or minor problem
|
Minimal or None
|
Minimal
|
|
99203
99213
|
Low
|
Low
• 2 or more self-limited/ minor problems or
• 1 stable chronic illness or
• 1 acute uncomplicated illness or injury
|
Limited (At least 1 category)
Category 1: Tests and documents (at least 2 data points required):
• Review of prior external note(s) from each unique source
• Review of the result(s) of each unique test
• Ordering of each unique test
Category 2:
• Assessment requiring independent historian(s)
|
Low
|
|
99204
99214
|
Moderate
|
Moderate
• 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment or
• 2 or more stable chronic illnesses or
• 1 undiagnosed new problem with uncertain prognosis or
• 1 acute illness with systemic symptoms or
• 1 acute complicated injury
|
Moderate
(At least 1 category required):
Category 1: Tests, documents, or independent historian(s)
(At least 3 data points requires):
• Review of external note(s)
• Review of result(s) of unique tests
• Ordering of unique test
• Assessment requiring independent historian(s)
Category 2: Independent interpretation of tests
• Independent test interpretation performed by another physician or healthcare professional
Category 3: Discussion of management/test interpretation
• Discussion of management/test interpretation with another physician/healthcare professional
|
Moderate
Examples:
• Prescription management
• Minor surgery decision with identified patient or procedure risk factors
• Elective major surgery decision without identified patient or procedure risk factors
• Diagnosis/treatment significantly limited by social determinants of health
|
|
99205
99215
|
High
|
High
• 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment or
• 1 acute or chronic illness or injury that poses a threat to life or bodily function
|
Extensive (Must meet requirements of at least 2 out of 3 categories):
Category 1: Tests, documents, or independent historian(s)
(at least 3 data points required):
• Review of external note(s)
• Review of test result(s)
• Ordering test(s)
• Assessment requiring independent historian(s)
Category 2: Independent interpretation of tests
• Independent test interpretation performed by another physician or healthcare professional
Category 3: Discussion of management/test interpretation
• Discussion of management/test interpretation with external physician/other source
|
High
Examples:
• Prescriptions requiring intensive monitoring for toxicity
• Elective major surgery decision with identified patient or procedure risk factors
• Emergency major surgery decision
• Hospitalization decision
• Decision not to resuscitate or to deescalate care because of poor prognosis
|
Again, you only need 2 of the 3 areas (diagnoses, data, and risk) at the same MDM level to justify the billing level.
NOTE: A 99211 visit is a “nursing visit.” It has no documentation requirements for the physician, although the nurse documents and sometimes sends it to the physician for review. Examples might include suture removal, dressing changes, weight and color checks for newborns, or nursing education. If the visit is exclusively for an injection (e.g., vaccine administration or Vitamin B12) without any nursing counseling or clinical judgment required, there are injection administration codes that should be used instead. However, if a nurse must use clinical judgment, such as assessing if a patient might be pregnant or ruling out contraindications to the intervention, then a nursing visit code should be used.
Pro-Tip: You should not bill based on “gestalt” which will lead to inadvertently under-coding and/or over-coding. Instead, you can optimize billing using any combination of diagnoses, data, and risk. It may be easiest to first learn how to code based on the number/complexity of problems addressed (diagnoses) and the risk. You can then add the data points into that scheme. In addition, focus on the differences between billing levels, i.e., learn the differences between 99204/99214 and 99203/99213, and the differences between 99204/99214 and 99205/99215. This makes it easier to learn (see examples 5 and 6 below). In addition, some general guidelines can make it easier, e.g., if you prescribe or refill medications (medication management) or order/review at least 3 unique labs or outside/specialist notes, think about how this frequently can “bump you” to a level 4.
Examples: Let’s try a few examples (use the above chart):
Example 1: Patient presents for controlled hypertension and hyperlipidemia (“2 stable chronic illnesses”). After evaluation, you decide to continue lisinopril at the same dose (“prescription management” which applies to any situation where you decide to continue, change, start, or stop prescription medications).
→ Billing Level: 99204/99214
Reason: Two of the three areas are in the moderate complexity row (Number and Complexity of Problems or Diagnoses and Risk of Complications and/or Morbidity/Mortality with or without further testing or treatment).
Example 2: Patient presents for uncontrolled diabetes mellitus (“1 or more chronic illness with exacerbation, progression, or side effects of treatment,” aka, 1 uncontrolled chronic problem). You increase the dose of metformin (prescription management, which applies to any situation where you decide to continue, change, start, or stop prescription medications).
→ Billing Level: 99204/99214
Reason: Two of the three areas are in the moderate complexity row (Number and Complexity of Problems or Diagnoses and Risk of Complications and/or Morbidity/Mortality with or without further testing or treatment).
Example 3: Patient presents with a painful breast lump (“1 undiagnosed new problem with uncertain prognosis” since you are evaluating for cancer), and chronic fatigue (“1 or more chronic illness with exacerbation, progression, or side effects of treatment” since it is a chronic, persistent/uncontrolled problem), and you order mammogram to evaluate the breast lump, as well as TSH and CBC to evaluate the chronic fatigue (“ordering of each unique test” since you ordered 3 tests—a mammogram and 2 unique lab tests).
→ Billing Level: 99204/99214
Reason: Two of the three areas are in the moderate complexity row (Number and Complexity of Problems or Diagnoses and Amount and/or complexity of data to be reviewed).
Example 4: Patient presents with COPD exacerbation with new hypoxia/low oxygen saturation in the office of 86% (“1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment”), and you advise them to go to the emergency department to be admitted to the hospital (“decision regarding hospitalization”).
→ Billing Level: 99205/99215
Reason: Two of the three areas are in the high complexity row (Number and Complexity of Problems or Diagnoses and Risk of Complications and/or Morbidity/Mortality with or without further testing or treatment).
Example 5: Patient presents with dysuria, but no fevers, chills, nausea, vomiting, or flank pain. No medical comorbidities. You perform a point-of-care urinalysis in the office, which is consistent with urinary tract infection (“1 acute uncomplicated illness or injury”), and you prescribe nitrofurantoin (“prescription management”).
→ Billing Level: 99203/99213
Reason: Two of the three areas are at least in the low complexity row (Number and Complexity of Problems or Diagnoses is in the low complexity MDM row and Risk of Complications and/or Morbidity/Mortality with or without further testing or treatment is the moderate complexity row). Since both meet criteria for low complexity, but they don’t both meet criteria for moderate complexity; you need at least two areas of the same complexity, so overall, ent is in the moderate complexity row). Since both meet criteria for low complexity, but they don’t both meet criteria for moderate complexity; you need at least two areas of the same complexity, so overall, this has low complexity MDM.
Reason: Two of the three areas are at least in the low complexity row (Number and Complexity of Problems or Diagnoses is in the low complexity MDM row and Risk of Complications and/or Morbidity/Mortality with or without further testing or treatment is in the moderate complexity row). Since both meet criteria for low complexity, but they don’t both meet criteria for moderate complexity; you need at least two areas of the same complexity, so overall, this has low complexity MDM.
Example 5b: What if the same patient had had fever and you treated for pyelonephritis?
→ Billing level: 99204/99214
Reason: There would now be “1 acute illness with systemic symptoms” (Number and Complexity of Problems or Diagnoses), which is of moderate complexity, in addition to “drug management;” so there would be two of the three areas in the moderate complexity row.
Time-Based Coding
Time-based coding is more straightforward, but you must document the time you spent caring for the patient. This time does not have to all be face-to-face and includes time reviewing the patient’s chart, seeing the patient, charting, and all care for the patient on the same day of the clinic visit. This includes time after the visit (on the same day) if you have to call about a result or if you need to call another healthcare provider to coordinate urgent care. Note that there is a slight difference of time between new and established patients.
Pro-tip: Established Patient starting times increase at 10- 20- 30- 40-minute intervals; New Patient starting times increase at 15- 30- 45- 60-minute intervals.
Note: If a visit exceeds the level 5 time requirement, there is a code for each additional 15 minutes: 99417. See “Prolonged Services” (on the day of face-to-face visit) section for more information.
The challenge with time-based coding is it must be an accurate reflection of time and may be more difficult to justify if charts are audited. Some EHRs have time-based tracking for your time in the patient’s chart, and phone call start and stop times should be recorded. You don’t necessarily need to split out the times for chart review, patient interaction, coordination with other caregivers, and documentation. However, whatever system of time-tracking you use, make sure it’s accurate and consistently utilized, so you can document the total time you spent and what you did during that time.
Example 1: “I spent 33 minutes caring for this patient today, including chart review, obtaining pertinent history, doing a physical exam, discussing management plan, and completing EHR documentation.”
→ Billing Level: If Established - 99214; If New - 99203
Norms of Routine Office Visit Coding
If you deviate significantly from expected benchmarks, you may be more likely to be audited by CMS or private health insurance payers. You may wish to compare your coding practices to other physicians in your practice or region and to national norms. For Established patients, family physicians usually code about 50% as Level 3 and 45% as Level 4. The remaining 5% are divided between Levels 1, 2, and 5. However, if you have more complex patients, you may end up coding a higher percentage of higher level visits. You can compare your own CPT codes against national averages at the AAPC Utilization Benchmarking Tool online.
Many physicians under-bill for services. If you have more complex patients and deviate from norms, you should still code appropriately; just ensure your documentation is clear to support your billing level.
Pro-tip: You should always document and code accurately for each patient and be certain you can justify your billing, especially if they deviate from expected norms. Ensure your documentation isn’t in a “gray-zone” that could be interpreted differently by different individuals, otherwise, an auditor may fine you for over-billing or under-billing.
Separate Routine Office Visits From Preventive Visits
Preventive Care involves different codes than “routine office visits” (covered in the next section). However, during preventive care visits, medical issues often arise. For minor issues, you should use the preventive care code alone (see the next section) and may include the ICD-10 codes for these minor issues. However, if there are acute or chronic issues, there are three options:
1. You may decide to reschedule the preventive care visit and focus on these specific acute or chronic issues, thus billing as a routine office visit.
2. You may continue with the wellness exam only, and suggest the patient schedule another appointment for acute or chronic care.
3. If you have time, you can address both acute/chronic issues and complete a preventive care visit. If you do both, you should bill the preventive care code first, followed by the routine office visit code with -25 modifier to indicate that a separate service was provided on the same day as the preventive care. (Note: modifiers are covered later on page XX[1] ).
Be aware that patients with health insurance may be charged a copay and/or additional costs for routine office visits, but not for preventive care services. Some patients may try to lump acute or chronic care into their preventive care visit. While it’s important to be sensitive to a patient’s financial and social situation, adding additional issues during a preventive visit can result in inadequate attention to both preventive care recommendations and to the acute/chronic issues. Should you choose to address both, ensure you can effectively do both with the time you have available. Clear communication is recommended to ensure the patient is aware of any copay/costs and time requirements of addressing these acute or chronic issues while maintaining quality of care. Also, if it’s a concern to you, ensure the visit agenda isn’t overextended so that you maintain both patient satisfaction and care quality.
Example 1: An established 13-year-old patient presents for his annual physical, but also has poorly controlled asthma and feels he’s currently having a “flair.” You discuss with the family about this issue being outside the preventive care visit and requires an office visit, but you can do both. They wish to address both and note they don’t have any co-pays. You perform all recommended preventive care services, and treat his asthma exacerbation (1 chronic problem, exacerbation = moderate MDM; 2 refills and a new medication = moderate risk/MDM).
→ Billing Level: Pediatric wellness exam, established patient: 99394 -25 (a -25 modifier) AND established patient: 99214
Example 2: A patient presents for a “well woman exam” but has poorly controlled diabetes and a laundry list of other issues to discuss, including a mole she would like removed and cryoablation of some lesions. She hasn’t come to the office in more than 3 years and says she wants “the most bang for her buck.” You don’t have time in your schedule for all these things. You inform her that you can only effectively address her well woman exam or her medical problems in the time you have together that day, but would be happy to have her scheduled back to address what isn’t covered. You also note that her skin procedures require a separate visit. She’s upset, but agrees to preventive care because she wasn’t prepared for a co-pay today. You address all preventive care recommendations and schedule her for a routine office visit and for the dermatology procedures.
→ Billing Level: Adult wellness exam, new patient (because it has been more than 3 years): 99385.