2015 EM Survival Guides Chapter 1: Office or Other Outpatient Visit (99201-99215) You should apply 99201-99215 for E/M visits in the office or other outpatient setting. These codes distinguish between new (99201-99205) and established (99211-99215) patients. You should select the appropriate E/M service level based on the medical necessity of performing the key components and then reviewing the documentation of the key E/M criteria of history, exam and medical decision-making (MDM). Exception: You can use time as the controlling factor to report office and other outpatient visits if more than 50 percent of the visit comprises counseling and coordination of care. See the Time chapter for complete instructions regarding how to code using time as the controlling E/M factor. Determine New or Established Status Generally, you should consider a patient to be established if the same physician, or any physician in your group practice (or, to be more precise, any physician of the same specialty or subspecialty billing under the same group number), has seen that patient for a face-to-face service within the past 36 months. Example: A patient saw a neurosurgeon 26 months ago. The patient now returns to see the neurosurgeon after being referred by his primary-care physician for symptoms of low-back pain. Because the neurosurgeon provided a service to the patient within the past three years, you should consider this patient to be established. Be aware: There may be some exceptions to the new vs. established patient rule for specialty or subspecialty within the same group practice. See the New vs. Established Patients chapter for complete details. For new patients, you should select from among codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent face-to-face with the patient and/or family). For established patients you will choose the appropriate E/M service level from the CPT 99211 (Office or other outpatient visit...that may not require the presence of a physician or other qualified healthcare professional. Usually these services) and ranges 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent face-to-face with the patient and/or family). Heed Revised Definitions of New and Established Patients 2013 brought new wording to the New and Established Patient section in the E/M services guidelines in the front of the CPT book. The underlined passages in the text below show the revisions: The definition of a new patient is one who has not received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. Similarly, an established patient is one who has received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. For New Patients, You ll Need 3 of 3 Criteria Code History Exam MDM
99201 Problem-focused Problem-focused Straightforward 99202 Expanded problem-focused Expanded problem-focused Straightforward 99203 Detailed Detailed Low complexity 99204 Comprehensive Comprehensive Moderate complexity 99205 Comprehensive Comprehensive High complexity When selecting an E/M service level for a new patient office or other outpatient visit (99201-99205), you must have all three key components to report the code appropriately in addition to the medical necessity for performing the elements. In practice, this means that the lowest key component will always determine the E/M service level. For new patient office visits, you ll use the following criteria for selecting the appropriate code: Example: The physician sees a new patient for an outpatient visit. She documents a comprehensive history and exam, and MDM of low complexity. In this case, you must choose 99203. Although the history and exam rise to the level of 99204 or even 99205, the lowest key component (in this case, the MDM) determines the correct service level. Therefore, you should select 99203 for this visit. For Established patients, 2 Out of 3 Will Do When choosing an E/M code for an established patient (99211-99215), you only need two of three key components to support the service level, as follows: Code History Exam MDM 99211 (Usually, the presenting problems are minimal) 99212 Problem-focused Problem-focused Straightforward 99213 Expanded problem-focused Expanded problem- focused Low complexity 99214 Detailed Detailed Moderate complexity 99215 Comprehensive Comprehensive High complexity Example: The physician sees an established patient in the office. The encounter documentation supports a problemfocused history, expanded problem-focused exam and low-complexity MDM. In this case, your best choice is 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent face-to-face with the patient and/or family) assuming the medical necessity is present for the services expanded problem-focused exam and low MDM. Although the history meets the requirements of 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent face-to-face with the patient and/or family) only, both the exam and MDM support 99213. Because you need only two of three key components when selecting an established outpatient E/M service, 99213 is correct. Important: In all cases (whether for a new or established patient) medical necessity must determine the extent of history, exam and MDM. In other words: If the presenting problem won t support a high-level E/M service, you can t get paid for the service just because the physician documented a comprehensive history and exam and high complexity MDM. Medical necessity must determine the service level the physician provides.
Making the Most of 99211 Code 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 healthcare professional. Usually, the presenting problem(s) are minimal) differs from the other office visit codes in that it does not require the three E/M components. In addition, the code descriptor specifies that the visit may not require the presence of a physician. The advantage: You can report 99211 for brief but medically necessary visits either with the physician or with a nurse or other applicable nonphysician practitioners (NPPs), such as physician assistants (PA), nurse practitioners (NP) and certified nurse specialists (CNS). Example: You can bill 99211 for blood pressure monitoring for hypertensive patients under a physicians plan of care, as long as there is established medical necessity for the blood pressure check. For instance, a surgeon examines a 65-year-old female patient during a preoperative exam and finds that her blood pressure is high. He decides to put her on medication to correct the problem. He notes in the chart, the patient should return in two weeks to see the nurse for a blood pressure check, an evaluation of how the new BP medicine is working, and follow-up. The surgeons notes indicate medical necessity for reporting 99211 when the patient returns. In this case, therefore, you could report 99211 for a low-level visit to the nurse or medical assistant to check the patient s blood pressure. Warning: If a patient comes in to have her blood pressure checked by the nurse just because the physician said that she should have it monitored every two weeks, you probably can t support a separate visit. You should consider providing a blood pressure check in the absence of other problems as a good-will gesture that does not constitute medical necessity for billing 99211. 99211 Do s and Don ts When considering 99211, remember these important points for proper reporting: Do: Make sure there is a separate E/M service. Check for a documented evaluation, along with management of the patients care. For example, if the nurse only refills the patient s medications and no other E/M service takes place, you should not report 99211. Ensure the patient is an established patient. Based on the CPT code description, you should report 99211 for a patient that has been seen by the rendering physician within the past three years, in any setting. Therefore, you cannot report 99211 for a new patient. For a visit to qualify for incident-to billing, the physician must have done a plan of care that calls for the incident-to personnel to perform the care provided. A physician (or nonphysician practitioner billed out under the physician s number) must see new patients, or established patients who have new problems, before you can report 99211 for an incident-to visit. For example, an established patient with a previous diagnosis of migraines comes to see a neurologist in the office with a complaint of numbness in his hands. Even if the complaint is minor, the neurologist must see the patient because this is a new problem. On a subsequent follow-up visit for the same problem, however, the nurse could see the patient if it is appropriate given the complaint and medical necessity and report 99211. Be certain that the physician is in the office: Reporting 99211 to certain payers (including Medicare) requires that the physician be in the office suite at the time of the appointment. The doctor is not required, however, to be in the room or provide face-to-face services for the patient. Prove that the nurse visit is medically necessary: Look for a documented clinical reason that supports the nurse visit and proves it was above the scope of the other services provided that day. If reporting the code with a procedure, make sure
the documentation is significant and separately identifiable. For example: The nurse should document the reason for the visit, a brief history of the patients illness, any exam processes such as weight or temperature, list of patients medications and a brief assessment. Bill the service out under the physician: who is present supervising the incident-to nursing visit, not necessarily the patient s doctor. All incident-to services must be billed under the doctor present in the office when they were provided. Don t: Bill for a nurse visit for services that are part of another E/M service performed on the same day: For example, if your nurse measures the patient s blood pressure and weight prior to her visit with the physician or provides counseling after the physician has seen the patient, you should not use 99211 because those tasks are considered part of the physician s office visit. Report 99211 for telephone calls: There must be face-to-face contact to report 99211. For example, if a nurse returns a patients call and gives instructions over the phone, you can t submit 99211 for reimbursement. Underestimate the importance of documentation: Documentation is essential when requesting reimbursement for nurse visits. The care provider must document the reason for and details of the encounter, which may include educational services as well as evaluation of the patient s condition with management directed by the physician. For example, you must have documentation to show that the supervising physician was in the office at the time of the visit. In this instance, your documentation might be a statement indicating that the nurse was working under a physician in the office or a copy of the physician s schedule, which shows she was in the office at the time of the nurse visit. The physician may alternatively decide to include a comment with his signature and the date. Beware Multiple Same-day E/Ms Although 99201-99205, 99211 (Office or other outpatient visit...that may not require the presence of a physician or other qualified healthcare professional. Usually these services), and 99212-99215 (Office or other outpatient visit Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent face-t- -face with the patient and/or family) are per episode rather than per day codes, you generally will not report more than one outpatient visit code per patient, per day. Heres why: Medicare payers will consistently combine or deny multiple same-day outpatient visits, unless you can show that the visits were for totally unrelated problems. Heres what you should do: If your physician sees the patient twice on the same day, combine the elements of history, exam and MDM for the two visits, and select a single E/ M service code that best describes the combined service. Example: If a patient comes in with elevated blood pressure due to hypertension and diabetes, the physician may give her medication and encourage her to come back later that day. In this case, because the visits are for the same complaint, you would combine the two visits into a single E/M service. A different problem on the same day could call for a separate service code. Your documentation should clearly show, however, that a different complaint/diagnosis prompted each service. Example: A patient comes in with diabetes and hypertension for a monthly follow- up visit, but then returns later that day reporting that she s been vomiting for the past two hours. In this case, because the complaints are unrelated, you may report the E/M services separately and maintain separate documentation showing the history, exam, MDM and diagnosis are different for each visit. Same-day Service or Procedure Calls for a Modifier If you report a separate and significant E/M service, including outpatient visits 99201-99215, on the same day as another service or procedure, you will in most cases have to append a modifier to the E/M service code. This is because minor procedures (those with zero- or 10-day global periods and per Correct Coding Initiative Narrative 7.2, XXX global period procedures) include a minor history and physical (H&P) associated with the procedure. Therefore, an E/M is payable only if
the provided E/M is substantially greater than the minor history, exam and MDM associated with the H&P associated with the procedure. For significant, separately identifiable E/M services on the same day as another service or minor procedure, you will append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code. Example: A new patient arrives with a complaint of intense heartburn and abdominal pain. The physician takes a complete history and performs an extensive exam. She then performs diagnostic endoscopy to check for reflux disease. In this case, you will report the endoscopy (43200, Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)). Separate documentation will also support a level-three outpatient visit (99203), to which you should append modifier 25. Although Medicare and AMAs CPT state that the physician does not need a different diagnosis for the E/M service and the procedure, it helps when supporting the significant and separately identifiable nature of the E/M from the procedure if you have more than one diagnosis. If you don t have more than one definitive diagnosis, many times there are signs and symptoms why the patient came to the doctor to begin with and there are final diagnoses after the work up is complete. When this is the case, you should link the signs and symptoms that prompted the exam (787.1, Heartburn; and 789.00, Abdominal pain; unspecified site) to the E/M code. You can link the same signs-and-symptoms diagnoses to the endoscopy if there are no positive findings. Or if the surgeon finds verifiable evidence of reflux disease (530.81), you can report that diagnosis as primary with the signs and symptoms as secondary. For major procedures (that is, any procedure with a 90-day global period) on the same or next day as the E/M service that prompted the physicians decision to perform the procedure, you should append modifier 57 (Decision for surgery) to the E/M service code. Important: You may not bill for the initial E/M service if the surgery was scheduled prior to the E/M service, however. Example: The surgeon sees a patient with extreme pain in the lower abdomen. The surgeon quickly determines that the patient s appendix has burst and schedules immediate surgery. In this case, both the E/M service and the surgery are billable because the E/M service resulted in the decision to perform the surgery (in other words, the surgery was not previously planned at the time of the evaluation). - Published on 2018-01-01