office visit in medical billing

Welcome to our article on understanding CPT code 99213 for medical billing. In the complex world of healthcare reimbursement and coding, it is crucial to have a clear understanding of the guidelines and requirements for using this particular code. CPT code 99213 is commonly used to describe an established patient office or other outpatient visit that lasts between 20-29 minutes. It requires a medically appropriate history and/or examination, as well as a low level of medical decision making.

Key Takeaways:

• CPT code 99213 is used to describe an established patient office or other outpatient visit lasting between 20-29 minutes.
• It requires a medically appropriate history and/or examination, as well as a low level of medical decision making.
• Understanding the guidelines and requirements for this code is essential for accurate medical billing and coding.
• Proper documentation and compliance with coding guidelines are crucial for efficient healthcare reimbursement.
• Medical Bill Gurus, led by President Daniel Lynch, offers comprehensive medical billing services and expertise in navigating the complexities of medical coding and billing.

The Importance of CPT Codes in Healthcare

CPT codes, also known as Current Procedural Terminology codes, play a crucial role in healthcare. These standardized codes are used to describe medical procedures and services, allowing for accurate communication between healthcare providers and ensuring proper documentation, billing, and reimbursement.

The use of CPT codes enables effective communication between healthcare providers, ensuring that the procedures and services provided are accurately described and understood. This is essential for maintaining consistency and clarity throughout the healthcare industry.

Accurate coding using CPT codes is also vital for proper documentation, billing, and reimbursement. By assigning the appropriate code to each medical procedure or service, healthcare providers can ensure that they receive payment for the care they provide and that insurance companies accurately process claims. This helps to streamline the billing and reimbursement process and minimize errors or discrepancies.

CPT codes also facilitate compliance with coding guidelines. These guidelines provide instructions on how to properly use and interpret each code, ensuring that the coding process is consistent and objective. By adhering to these guidelines, healthcare providers can ensure that their coding practices are in line with industry standards and avoid any potential compliance issues.

In addition to their role in documentation, billing, and compliance, CPT codes are valuable for data analysis and research purposes. These codes allow for the collection and analysis of data on medical procedures and services, providing valuable insights into healthcare trends, patient outcomes, and resource utilization. Such data can help improve the quality of care, inform healthcare policies, and contribute to advancements in medical research and technology.

Understanding the purpose and function of CPT codes is essential in the healthcare industry. It allows for accurate communication, proper documentation, billing and reimbursement, compliance with coding guidelines, and valuable data analysis. By utilizing CPT codes effectively, healthcare providers can streamline their operations and contribute to improved patient care.

Overview of CPT Code 99213

CPT code 99213 is a crucial code used in medical billing to document and bill for services provided during an outpatient office visit with an established patient. This code represents a level 3 office visit and covers evaluation and management services.

During a 99213 office visit, healthcare providers assess the patient’s medical history, conduct a physical examination, diagnose and treat medical conditions, prescribe medications, and provide counseling or education. This comprehensive evaluation and management process ensures that patients receive the necessary care and treatment for their healthcare needs.

The duration of a typical 99213 office visit ranges from 20 to 29 minutes, allowing healthcare providers sufficient time to thoroughly assess and address the patient’s medical concerns.

Understanding Medical Decision Making for CPT Code 99213

Medical decision making plays a critical role in determining the appropriate use of CPT code 99213 during patient encounters. It involves assessing three key parameters: the problems addressed, the data reviewed, and the level of risk. By evaluating these factors, healthcare professionals can accurately determine the complexity of the medical decision making process. This understanding is vital for coding and billing with CPT code 99213, ensuring proper documentation and reimbursement.

Medicare’s Documentation Guidelines for Evaluation and Management Services provide valuable tables that assist in calculating the level of medical decision making. These tables help healthcare providers evaluate the extent of the problems addressed, the extent of the data reviewed, and the level of risk involved. By utilizing these tables, healthcare professionals can accurately assess the medical decision making complexity associated with a patient encounter.

Accurately assessing the complexity of medical decision making is crucial when using CPT code 99213 for evaluation and management services. It allows healthcare providers to effectively capture the level of service provided to the patient and ensure appropriate reimbursement. Understanding the guidelines and tables provided by Medicare supports accurate coding and billing practices.

Coding Accurately for CPT Code 99213

Accurately documenting and coding medical decision making is essential when using CPT code 99213. Healthcare professionals must carefully assess the problems addressed, the data reviewed, and the level of risk to determine the appropriate level of medical decision making. Medicare’s documentation guidelines and tables provide valuable guidance in this process.

By understanding the principles of medical decision making and utilizing the resources available, healthcare professionals can ensure accurate coding and billing practices with CPT code 99213. This in turn supports proper reimbursement and compliance with coding guidelines.

Differentiating Between Low Complexity and Moderate Complexity

Differentiating between low complexity and moderate complexity medical decision making is essential when using CPT code 99213. By understanding the criteria for each level of complexity, healthcare providers can accurately determine the appropriate code to use. To assess complexity, Medicare’s Documentation Guidelines provide a point system that evaluates the problems addressed, data reviewed, and level of risk involved in the patient encounter.

In low complexity medical decision making, fewer points are required to meet the criteria. This indicates that the patient’s condition is straightforward, and the necessary medical interventions are simple. On the other hand, moderate complexity medical decision making requires a higher number of points, signifying a more complex patient case and a greater level of medical intervention and management.

To accurately differentiate between low complexity and moderate complexity, healthcare providers must carefully evaluate the patient encounter and assign the appropriate number of points based on the documentation and complexity of the patient’s condition. This ensures the correct use of CPT code 99213, leading to accurate coding, billing, and reimbursement.

Understanding the nuances of low complexity and moderate complexity medical decision making empowers healthcare providers to provide appropriate care while adhering to coding guidelines and achieving accurate reimbursement.

Check out the chart below for a visual representation of the differences between low complexity and moderate complexity medical decision making:

Proper Documentation for CPT Code 99213

Proper documentation plays a crucial role in supporting the use of CPT code 99213 for medical billing and coding. It ensures a clear and accurate record of the patient’s encounter and helps determine the appropriate level of service provided. The documentation for CPT code 99213 should include the following key elements:

Patient’s Medical History

Include thorough documentation of the patient’s medical history, including any relevant past illnesses, surgeries, medications, and allergies. This information provides necessary context for understanding the patient’s current condition and helps in making informed medical decisions.

Nature of the Presenting Problem

Document a detailed description of the presenting problem or reason for the visit. Include information about the symptoms, duration, severity, and any associated factors. This documentation helps in accurately assessing and diagnosing the patient’s condition.

Scope of the Examination

Describe the extent of the examination conducted during the patient encounter. Document the areas examined, any diagnostic tests performed, and the results obtained. This information supports the medical necessity of the examination and helps determine the appropriate level of service.

Medical Decision-Making Process

Provide a thorough explanation of the medical decision-making process involved in the patient’s care. Document the diagnoses, treatment options considered, and the final treatment plan chosen. Include any consultations with other healthcare providers or specialists. This documentation helps demonstrate the complexity of the medical decision making and justifies the use of CPT code 99213.

Treatments or Interventions Provided

Include detailed information about any treatments, procedures, counseling, or education provided to the patient during the encounter. Document the specific services rendered, such as medication prescriptions, referrals, or patient education materials. This documentation supports accurate coding and billing for the services performed.

Accurate and thorough documentation is essential for compliance with coding and billing requirements, ensuring proper reimbursement, and facilitating effective communication among healthcare teams. Healthcare providers should establish comprehensive documentation processes for CPT code 99213 visits to maintain accurate medical records and support optimal patient care.

The Role of the AMA in CPT Codes

The American Medical Association (AMA) plays a vital role in the development and maintenance of the CPT code set, which is the standard for medical coding in the healthcare industry. As the authority on CPT codes, the AMA continuously manages and updates the code set to ensure its accuracy and relevance in reflecting current clinical practices and innovations in medicine.

To ensure that the CPT code set remains up-to-date, the AMA relies on the expertise of the CPT Editorial Panel. This panel consists of practicing physicians who review and revise the codes to keep pace with advancements in medical science and technology. By doing so, the AMA ensures that healthcare professionals have access to a comprehensive and accurate coding system.

The involvement and guidance of the AMA in the development and maintenance of CPT codes are invaluable to the healthcare industry. As medical coding is an essential component of healthcare reimbursement and data analysis, the AMA’s efforts support accurate billing, effective communication between healthcare providers and insurance companies, and reliable data collection and research.

AMA’s Contribution to CPT Code Set

The AMA’s participation in the development and maintenance of the CPT code set goes beyond managing updates. They also provide comprehensive guidelines and resources that assist healthcare professionals in correctly utilizing the codes. These guidelines ensure consistency and accuracy in documenting medical services, promoting coding compliance and reducing errors in medical billing.

By working closely with physicians and healthcare experts, the AMA ensures that the CPT code set reflects the real-world experience and expertise of those on the front lines of patient care. This collaborative approach contributes to the credibility and effectiveness of the CPT code set, making it a valuable tool for accurate medical coding.

The AMA and Medical Coding Education

In addition to its role in the development and maintenance of the CPT code set, the AMA also plays a crucial role in medical coding education. The organization provides a variety of educational resources and programs to help healthcare professionals stay current with coding guidelines and best practices.

Through their coding education initiatives, the AMA supports the ongoing professional development of coders and healthcare providers. By staying informed about the latest coding updates and guidelines, healthcare professionals can ensure accurate and compliant coding practices, leading to more efficient reimbursement and better patient care.

The Purpose of the CPT Code System

The CPT code system serves several important purposes in healthcare. Developed and maintained by the American Medical Association (AMA), it provides a standardized set of codes to describe medical procedures and services, ensuring clear communication between healthcare providers and insurance companies.

One of the key functions of the CPT code system is facilitating accurate billing and reimbursement. By assigning specific codes to medical procedures, healthcare providers can accurately document and bill for the services they provide, reducing errors and ensuring fair reimbursement for the care delivered.

Furthermore, the CPT code system plays a vital role in data collection and research. The use of standardized codes allows for consistent data collection across healthcare facilities and enables researchers to analyze trends and outcomes, ultimately driving improvements in patient care.

Another important aspect of the CPT code system is ensuring consistency and accuracy in documenting medical services. By using the same set of codes, healthcare providers can effectively communicate the nature and complexity of procedures performed, enabling seamless transitions in patient care and promoting continuity throughout the healthcare system.

Overall, the CPT code system is an indispensable tool in the healthcare industry. It facilitates effective communication between healthcare providers and insurance companies, enables accurate billing and reimbursement, supports data collection and research, and ensures consistency and accuracy in documenting medical services. Understanding the purpose and components of the CPT code system is essential for healthcare professionals involved in medical procedures, billing, and communication.

Categories and Subcategories of the CPT Code System

The CPT code system plays a vital role in accurately describing and documenting medical procedures and services. It organizes these procedures and services into different categories and subcategories, allowing for precise coding and billing. Familiarizing oneself with the categories, subcategories, and modifiers of the CPT code system is essential for healthcare professionals involved in medical billing and coding.

Evaluation and Management

The Evaluation and Management category of the CPT code system covers office visits, hospital visits, consultations, and other services related to the evaluation and management of a patient’s healthcare. This category encompasses various codes, including CPT code 99213, which represents an established patient office visit lasting between 20-29 minutes.

The Anesthesia category of the CPT code system includes codes that describe anesthesia services during surgical procedures or medical treatments. Anesthesia codes are unique, as they consider factors such as the patient’s age, physical status, and the complexity of the procedure.

The Surgery category of the CPT code system consists of codes that describe surgical procedures performed by healthcare providers. These codes provide specific information about the type of surgery, the anatomical location, and any additional procedures performed during the surgery.

The Radiology category of the CPT code system encompasses codes that describe diagnostic imaging procedures, such as X-rays, ultrasounds, MRIs, and CT scans. These codes provide detailed information about the type of imaging performed, the specific body part examined, and any contrast materials used.

Pathology and Laboratory

The Pathology and Laboratory category of the CPT code system includes codes that describe laboratory tests, including blood tests, urine tests, and tissue analyses. These codes provide information about the specific test performed, the method used, and the interpretation of the results.

The Medicine category of the CPT code system covers a broad range of medical services that do not fall into other specific categories. This includes services such as vaccinations, medication administration, and therapeutic procedures. The Medicine codes are further divided into subcategories based on the type of service provided.

In addition to the categories and subcategories, the CPT code system also includes modifiers. Modifiers are additional codes that provide extra information about the procedure. They can indicate that multiple procedures were performed, specify the anatomical location of the procedure, or indicate certain circumstances or complications.

Updates and Guidelines for the CPT Code System

The CPT code system constantly evolves to keep pace with advancements in medical technology, procedures, and practices. It is crucial for healthcare professionals to stay updated with the latest updates and guidelines to ensure accurate coding and billing.

The American Medical Association (AMA) provides comprehensive guidelines for each category and subcategory of the CPT code system. These guidelines ensure consistent and correct usage of codes, promoting standardized documentation and billing practices across the healthcare industry.

Continuous education and staying informed about the evolving CPT code system are essential for healthcare professionals. By staying updated, we can effectively adapt to the changes and maintain compliance with coding and reimbursement requirements.

Benefits of Staying Updated with CPT Code Updates Accurate coding: Staying updated with CPT code updates enables us to accurately code medical procedures and services, reducing the risk of billing errors and claim denials. Optimized reimbursement: By adhering to the latest guidelines, we can ensure that our claims are properly reimbursed, maximizing revenue for our healthcare practices. Compliance with regulations: Staying informed about CPT code updates helps us comply with regulatory requirements, such as those set by Medicare and other insurance payers. Improved communication: The use of up-to-date CPT codes facilitates effective communication between healthcare providers, insurance companies, and other stakeholders in the healthcare system.

Note: The table below outlines some recent updates to the CPT code system:

Staying updated with CPT code updates and following the established guidelines ensures accurate coding, proper documentation, and appropriate reimbursement for the medical services we provide. By remaining informed and engaged, we can navigate the complexities of the evolving medical landscape and continue to deliver quality healthcare to our patients.

Commonly Used CPT Codes in Medical Billing

In the healthcare industry, medical billing requires accurate coding and documentation to ensure proper reimbursement. Understanding commonly used CPT codes is crucial for healthcare providers. One such code that plays a significant role in medical billing is CPT code 99213.

CPT code 99213 is frequently used for office visits with established patients. This code represents a significant portion of physician encounters and is vital for accurately billing services provided during these visits. By understanding the appropriate use and documentation requirements for CPT code 99213, healthcare professionals can ensure accurate medical billing and coding practices.

CPT code 99213 is used to describe an evaluation and management service provided during an established patient office visit. It encompasses various elements, including assessing the patient’s medical history, conducting a physical examination, diagnosing and treating medical conditions, prescribing medications, and providing counseling or education.

Properly documenting the services provided during an office visit is essential for accurate medical billing. Healthcare providers should ensure comprehensive documentation that includes detailed information about the patient’s medical history, the nature of the presenting problem, the scope of the examination, the medical decision-making process, and any treatments or interventions provided.

Accurate coding of CPT code 99213 and proper documentation support ensures compliance with coding guidelines and facilitates proper reimbursement for healthcare providers.

Additionally, there are other commonly used CPT codes in medical billing that healthcare professionals should be familiar with. These codes vary based on the specific medical services provided and are essential for accurate billing and coding throughout the healthcare industry.

These are just a few examples of commonly used CPT codes in medical billing. The precise selection of the appropriate code depends on the complexity of the patient’s condition, the level of medical decision making, and the documentation requirements.

In summary, understanding commonly used CPT codes, such as CPT code 99213, is crucial for accurate medical billing and coding in the healthcare industry. By adhering to coding guidelines, documenting services provided, and staying informed about the latest updates, healthcare professionals can ensure efficient reimbursement and compliance with coding standards.

The Role of Medical Bill Gurus in Healthcare Billing

Medical Bill Gurus, led by President Daniel Lynch, is a trusted medical billing company that offers comprehensive billing services for healthcare providers. With our expertise and dedication, we ensure accurate and efficient medical billing processes, exceeding industry standards.

Our services cover billing for all insurance payers, including Medicare, Medicaid, and private insurance companies. We understand the complexities of healthcare reimbursement and work diligently to maximize revenue for our clients.

At Medical Bill Gurus, coding compliance is a top priority. Our team of experts stays up-to-date with the latest coding guidelines and regulations, ensuring that our clients’ medical billing practices are fully compliant. We provide thorough documentation review and coding audits to identify any potential issues and rectify them promptly.

Our commitment to efficient healthcare reimbursement sets us apart. We have extensive experience in handling billing for a wide range of medical specialties, enabling us to streamline the reimbursement process and ensure timely payments. Our meticulous approach and attention to detail result in improved cash flow and reduced billing errors.

The Benefits of Choosing Medical Bill Gurus:

• Comprehensive medical billing services for all insurance payers
• Expertise in coding compliance and adherence to guidelines
• Efficient healthcare reimbursement and improved cash flow
• Experienced team knowledgeable in medical coding and billing
• Thorough documentation review and coding audits
• Dedicated support and personalized solutions

With Medical Bill Gurus by your side, you can focus on providing quality patient care while we handle the complexities of medical billing. Trust us to maximize your revenue, ensure coding compliance, and optimize your billing processes.

Additional Resources for CPT Code 99213

In addition to the information provided in this article, there are additional resources available for understanding and utilizing CPT code 99213.

Medical Bill Gurus offers comprehensive medical billing services and can provide further guidance on accurate coding, documentation, and billing. Our team of experts is well-versed in the complexities of medical coding and billing, ensuring compliance with coding guidelines and efficient healthcare reimbursement.

Healthcare professionals can also refer to the American Medical Association’s resources on CPT codes for additional information and guidelines. The AMA serves as the authority on the CPT code set, regularly updating it to reflect advancements in medical technology and practices.

If you’re looking for reliable and in-depth information on CPT code 99213, consult Medical Bill Gurus and the resources provided by the American Medical Association.

Understanding CPT code 99213 is crucial for healthcare professionals involved in medical billing and coding. This code represents a level 3 outpatient office visit for established patients and requires proper documentation, accurate coding, and compliance with coding guidelines. By adhering to these requirements, healthcare providers can ensure efficient healthcare reimbursement and coding compliance.

Medical Bill Gurus, led by President Daniel Lynch, specializes in comprehensive medical billing services and offers expertise in navigating the complexities of medical coding and billing. With their assistance, healthcare providers can confidently navigate the nuances of CPT code 99213 and implement accurate and efficient medical billing practices.

It is crucial for healthcare professionals to familiarize themselves with the guidelines and requirements for using CPT code 99213. This knowledge ensures that the appropriate level of medical decision making is documented, and the associated billing is accurate. By prioritizing proper documentation, accurate coding, and compliance with coding guidelines, healthcare providers can optimize their medical billing practices and streamline the reimbursement process.

What is CPT code 99213?

CPT code 99213 is used to describe an established patient office or other outpatient visit that lasts between 20-29 minutes.

What is the purpose of CPT codes in healthcare?

CPT codes are a standardized system used to describe medical procedures and services. They facilitate effective communication, accurate billing and reimbursement, compliance with coding guidelines, and data analysis and research.

What does CPT code 99213 cover?

CPT code 99213 covers evaluation and management services provided during a standard office visit with an established patient, including assessing history, conducting physical examinations, diagnosing and treating medical conditions, prescribing medications, and providing counseling or education.

How does medical decision making impact the use of CPT code 99213?

Medical decision making is a key factor in determining the appropriate use of CPT code 99213. The level of medical decision making is determined by the problems addressed, data reviewed, and level of risk. Proper assessment of medical decision making complexity is vital for accurate coding and billing.

What is the difference between low complexity and moderate complexity medical decision making?

Low complexity medical decision making requires fewer points in the evaluation process, while moderate complexity medical decision making requires more points. Understanding the criteria for each level helps in correctly using CPT code 99213.

What documentation is required for CPT code 99213?

Proper documentation should include detailed information about the patient’s medical history, the presenting problem, the examination scope, the medical decision-making process, and any treatments or interventions provided. Accurate documentation ensures compliance and proper reimbursement.

How is the CPT code system maintained and updated?

The American Medical Association (AMA) is the authority on the CPT code set. The CPT Editorial Panel, consisting of practicing physicians, ensures the code set reflects current clinical practice and advancements in medicine.

What are the categories and subcategories of the CPT code system?

The CPT code system includes categories such as Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. Subcategories further define procedures and services.

How often is the CPT code system updated?

The CPT code system is regularly updated to reflect advancements in medical technology, procedures, and practices. Staying updated with the latest guidelines is essential for accurate coding and billing.

What are some commonly used CPT codes in medical billing?

CPT code 99213 is one of the most commonly used codes, representing a significant portion of physician encounters and frequently used for office visits with established patients.

What services does Medical Bill Gurus offer?

Medical Bill Gurus offers comprehensive medical billing services, including billing for all insurance payers, Medicare, and more. Their expert team helps healthcare providers navigate the complexities of medical coding and billing.

Where can I find additional resources for CPT code 99213?

Medical Bill Gurus can provide further guidance on accurate coding, documentation, and billing. Additionally, the American Medical Association offers resources on CPT codes for additional information and guidelines.

How important is it to understand CPT code 99213 in medical billing?

Understanding CPT code 99213 is crucial for accurate medical billing and coding. Compliance with coding guidelines and proper documentation ensures efficient healthcare reimbursement and coding compliance.

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Office Visits- E&M codes in Medical Billing

Office Visits: Understanding E&M Codes in Medical Billing

Evaluation and Management (E&M) codes are a critical component of medical billing, particularly for office visits. These codes, used by healthcare providers to document and bill for patient encounters, play a vital role in the revenue cycle. Understanding how E&M codes work and how to apply them correctly can ensure accurate billing, compliance, and optimal reimbursement. In this blog, we’ll explore what E&M codes are, the key factors in determining the appropriate code, and best practices for coding office visits.

What Are E&M Codes?

E&M codes are a subset of the Current Procedural Terminology (CPT) codes maintained by the American Medical Association (AMA). They are used to represent various levels of service provided during patient encounters, including office visits, hospital visits, consultations, and other types of interactions between healthcare providers and patients.

Each E&M code corresponds to a different level of service complexity, reflecting the amount of time, effort, and medical decision-making involved in the visit. For office visits, the most used E&M codes fall within the 99202-99215 range, covering both new and established patients.

Key Components of E&M Coding

Accurately determining the appropriate E&M code for an office visit involves evaluating three key components:

1.History: The extent of the patient’s history taken during the visit is a significant factor in E&M coding. This includes the chief complaint, history of present illness (HPI), review of systems (ROS), and past medical, family, and social history (PFSH). The history is categorized into problem-focused, expanded problem-focused, detailed, and comprehensive levels.

2.Examination: The physical examination performed by the healthcare provider is another crucial component. The examination can be problem-focused, expanded problem-focused, detailed, or comprehensive, depending on the number of body systems or areas examined and the depth of the assessment.

3.Medical Decision Making (MDM): MDM reflects the complexity of diagnosing and managing the patient’s condition. It considers factors like the number and nature of the problems addressed, the amount and complexity of data reviewed, and the risk of complications or morbidity. MDM is classified into straightforward, low complexity, moderate complexity, and high complexity levels.

In 2021, significant changes were made to E&M coding guidelines, particularly for office visits, emphasizing MDM and total time spent with the patient rather than focusing on history and examination. These changes were designed to reduce administrative burden and align coding more closely with the actual work involved in patient care.

Levels of E&M Codes for Office Visits

Here’s a brief overview of the E&M codes commonly used for office visits:

99202-99205: These codes apply to new patient visits, with 99202 representing the lowest level of service and 99205 the highest. The appropriate code is selected based on the complexity of MDM or the total time spent on the date of the encounter.

99212-99215: These codes are used for established patient visits, with 99212 being the lowest level and 99215 the highest. Similar to new patient codes, the selection is based on MDM complexity or total time.

The correct code must accurately reflect the level of care provided. Overcoding (billing for a higher level of service than provided) or under coding (billing for a lower level of service) can lead to compliance issues, claim denials, or lost revenue.

Best Practices for E&M Coding in Office Visits

To ensure accurate and compliant E&M coding for office visits, consider these best practices:

1.Stay Updated on Guidelines: E&M coding guidelines evolve, so it’s crucial to stay informed about the latest changes, such as the 2021 revisions. Regular training and resources like the AMA’s E&M guidelines can help keep your knowledge current.

2.Thorough Documentation: Comprehensive documentation is key to justifying the level of service billed. Ensure that all components of the visit—history, examination, and MDM—are well-documented. If time is used as the primary factor for coding, document the total time spent and the activities performed during that time.

3.Use Coding Tools: Many practices use coding tools or software to assist with E&M code selection. These tools can help ensure accuracy and consistency in coding, particularly when integrated with electronic health records (EHRs).

4.Regular Audits: Conduct regular internal audits of E&M coding to identify potential errors or patterns of overcoding or undercoding. Audits can also help prepare for external payer audits and reduce the risk of compliance issues.

5.Consult with Experts: When in doubt, consult with medical coding experts or certified professional coders (CPCs). Their expertise can help navigate complex coding scenarios and ensure compliance with payer requirements.

E&M codes are fundamental to billing for office visits in medical practice. Understanding the components and guidelines for selecting the appropriate E&M code is essential for accurate billing and optimal reimbursement. By staying informed, maintaining thorough documentation, and following best practices, healthcare providers can ensure their coding is both accurate and compliant.

For more insights and assistance with medical billing and coding, consider partnering with Total RCM Solutions. Our team of experts is dedicated to helping healthcare providers optimize their revenue cycles and navigate the complexities of medical billing. Contact us today to learn more about how we can support your practice.

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A Simpler Way to Code Office Encounters

A major update coming in january will finally make things much easier..

By John Rumpakis, OD, MBA

M ajor changes to the outpatient and office evaluation and management (E/M) codes are slated to go into effect on January 1, 2021. 1 These changes have been long awaited and will certainly reduce the administrative burden on the average practice by making coding your office encounters much easier and straightforward. The changes, made by the American Medical Association CPT Editorial Panel and others, are in response to the Centers for Medicare & Medicaid’s (CMS) request to collapse the E/M codes and reduce the burden of medical record keeping on the physician. 

A Look at the Past

The history of determining appropriate reimbursement levels for professional medical services is entrenched in mystery and confusion. For optometry, it began with the profession’s inclusion in the Federal Medicare program on April 1, 1987, which formally classified optometrists as physicians—an important milestone for medical reimbursement protocols in optometry.

The Medicare physician fee schedule is founded on the resource-based relative value system (RBRVS), which stemmed from the Harvard/American Medical Association’s (AMA) RBRVS developed in the late 1980s. The first RBRVS was a Harvard research study initiated by the government because of double-digit annual increases in the cost of medical care in the United States and a perceived opinion that physician fees based on the reasonable/usual/customary methodology were not consistent or equitable. To address this inequity, physician work values and practice expenses for key AMA CPT codes were determined by a survey and validated by physician consensus panels known as the Clinical Practice Expert Panels.

Based on this early RBRVS, the Health Care Finance Administration implemented the new RBRVS for Medicare physician reimbursement in 1992 for all CPT codes, using a crosswalk methodology to fill the gaps where surveyed data was not yet available. 

Today’s RBRVS is based on a series of relative value units (RVUs) associated with each CPT code. The three major elements of Medicare’s current system include: 

The relative value scale (RVS). This is a list of physician services ranked according to value. The total RVU, in turn, consists of three relative values: physician-work, practice expense and malpractice risk. Values for new and revised procedures in the CPT are included in the updated RVS each year. The malpractice risks are directly assigned by the CMS based on a survey of estimated risk levels by specialty. 

  The geographic adjustments. The RVS components are factored by a corresponding adjustment for the locality, as geographic adjustments to Medicare payment amounts were introduced in 1995. Three geographic practice cost indices (GPCIs, pronounced “gypsies”) were developed by private researchers, including the Urban Institute, with funding from the CMS. 

The conversion factor. Reimbursements are determined for each and every CPT code with a mathematical formula. The formula incorporates all six of the above variables and then uses a conversion factor determined by Congress in the budget-balancing process ( Figure 1 ). This factor is also published each year in the Federal Register . 

Changes on the Way

Starting January 1, 2021, performing a history and/or exam will still be medically appropriate for reporting all levels of an E/M service but will no longer play a significant role in the E/M code selection. Instead, providers will select the code based only on the level of medical decision making or total time. These other major changes—for the better—will also make workflow easier to code:

• Deletion of CPT code 99201: Due to low use of the level 1 code for office/other outpatient visit for the evaluation and management of a new patient, this code will be deleted in 2021.

• Although they are necessary factors when reporting an E/M visit, the history and exam elements will no longer be key in the office/outpatient E/M code selection.

• The definition of time associated with E/M levels 99202–99215 is changing from “typical face-to-face time” to “total time spent on the day of the encounter”—a critical distinction. Providers will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter. The time values associated with each of the revised office/outpatient E/M codes will reflect the total time spent.

• There are changes to the wording of the medical decision-making elements:

• “Number of diagnoses or management options” is changing to “number and complexity of problems addressed.”
• “Amount and/or complexity of data to be reviewed” is becoming “amount and/or complexity of data to be reviewed and analyzed.”
• “Risk of complications and/or morbidity or mortality” is changing to “risk of complications and/or morbidity or mortality of patient management.”

Practitioners will have a choice on factors to use to determine the E/M code for the encounter: time or medical decision making. That being said, time has a new definition as well, before being applied to the clinical circumstance: 1  

“When time is used to select the appropriate level for E/M services codes, time is defined by the service descriptors. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional. For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.”  

For coding purposes, time for office or other outpatient services (99202-99205, 99212-99215) is the total time on the date of the encounter, including both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s). This also encompasses the time spent in activities that require the physician or other qualified health care professional but does not include time in activities normally performed by clinical staff.

The physician’s or other qualified health care professional’s time includes the following activities, when performed:

• Preparing to see the patient (e.g., review of tests).
• Obtaining and/or reviewing separately obtained history.
• Performing a medically appropriate examination and/or evaluation.
• Counseling and educating the patient/family/caregiver.
• Ordering medications, tests or procedures.
• Referring and communicating with other health care professionals (when not separately reported).
• Documenting clinical information in the health record.
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
• Care coordination (not separately reported). 

These changes in how the practitioner’s total time is recorded will be helpful in achieving specific levels of coding for an individual encounter.

The new E/M code definitions clearly demonstrate the elimination of the history and exam requirements while emphasizing the time and/or medical decision-making elements by using the wording “medically appropriate history and/or examination.” 

Here are the new definitions: 1

New Patient (99201 has been deleted; to report, use 99202)

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

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

• 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or exam and moderate level of medical decision making. When using time for code selection, 45 to 59 minutes of total time is spent on the date of the encounter.

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

Established Patient

• 99211: This code may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.

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

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

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

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

Clinicians must ensure their electronic health record (EHR) has the ability to record total time spent while working in a patient’s record, so it will be easy to tally the total time, in minutes, spent on preparation, review, examination and so on. 

Medical Decision Making

Whether in the office or for other outpatient services, this code set is defined by three elements ( Table 1 ): 1

1. The number and complexity of problem(s) that are addressed during the encounter.

2. The amount and/or complexity of data involved. This includes medical records, tests and other information that must be obtained, ordered, reviewed and analyzed. It also encompasses information obtained from multiple sources or interprofessional communications not separately reported, as well as the interpretation of tests not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter, not a subsequent encounter. Data is divided into three categories: (1) tests, documents, orders or independent historian(s), where each unique test, order or document is counted to meet a threshold number; (2) independent interpretation of tests; and (3) discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source.

3. The risk of complications, morbidity and mortality of patient management decisions made at the visit, as it relates to the patient’s problem(s), diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with sufficient support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that warrants inpatient care, but for whom the goal is palliative treatment.

The new E/M coding system provides practitioners with both flexibility and choice due to the reduced administrative burden of documenting specific levels of history and examination to reach a particular code level. 

It is important to prepare your practice for these changes by ensuring that your EHR system allows for appropriate documentation of time and that you are tallying it correctly if you use time for the code determinant. If using medical decision making, spend the time between now and January to become familiar with the new requirements for documentation. They are not all that different from the previous methodologies, but they are just different enough that they warrant your attention. 

Change is coming and, for once, it just might make things easier. 

The information in this article is not intended as a substitute for AMA guidelines. For coding purposes, see the AMA’s original document at  www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf . 1  

Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. He is also  Review of Optometry ’s clinical coding editor and authors the monthly Coding Connection column.

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The noob-friendly guide to medical billing and coding for primary care.

Should you use 99213 or 99214 for your patient visit?

Most primary care clinicians don’t fully understand all the nuances they must consider when determining how to code for billing  for an office visit. Many leave money on the table and “undercode” for fear of being flagged or audited by CMS or commercial payers. While no reputable healthcare practitioner would purposefully commit billing fraud or abuse, no one wants to end up paying fines or facing legal allegations for unintentional violations. However, when it comes to medical billing, payers might not be able to differentiate between innocent mistakes and deliberate missteps.

Medical billing and coding is not taught in medical school and is only briefly reviewed during residency training. With an emphasis on outpatient primary care, the basic review below is a good guide for new or in-training physicians and a great refresher for seasoned clinicians.

Here is everything you will learn in this guide:

• Different types of office visits
• Elements of medical documentation
• How to determine the level of complexity of a visit
• Complexity of medical decision-making
• Other billable services

1. Different Types of Office Visits

When billing for an outpatient visit, you need to know whether you have a new or an established patient. If someone has been in your office for a visit at least once during the last three years, then they are an established patient; otherwise they are considered a new patient.

If you are in a multi-specialty group, a new patient is one who  has not been seen by a healthcare professional in your department in the last three years.

2. Elements of Medical Documentation

The Current Procedural Terminology (CPT) code range for Evaluation and Management (E/M) Services 99201-99499 is a medical code set maintained by the American Medical Association.

Several components of your documentation are used to define the level of the visit or E/M service you provide. Although there are up to five levels, a primary care clinician typically uses the highest three (i.e., 99213, 99214, rarely 99215 if it is an established patient, or 99202 and 99203 if it is a new patient. See table 1.).

There are several elements of medical documentation, but the key components are history, exam and medical decision-making (Table 2). Time is one element that can be used supplementally to determine the appropriate E/M service level, especially when documentation alone won’t reflect the amount of work that level of service requires.  An example would be if a patient came in for a single problem but you spent a significant amount of time providing counseling or coordinating care.

Face-to-face time, for documentation purposes, is the actual time spent with the patient. However, most clinicians spend some time before the visit reviewing the chart and after the visit completing the visit note. According to the CPT Professional 2020 , the face-to-face time associated with the services described by any E/M code is a valid proxy for the total work done before, during and after the visit.

Some clinicians could be tempted to  bill based on time for all their visits so they can bypass all the onerous medical documentation requirements. However, time-based billing is only appropriate when more than 50 percent of the encounter (face-to-face time) was spent on counseling or coordination of care. Having a good understanding of how to code and document properly can work in your favor, because sometimes billing for the actual complexity of the visit can result in a higher level of compensation. 

3. How to Determine Level of Complexity of a Visit

As mentioned earlier, three key components of your documentation determine the E/M service level for an outpatient visit: history, exam and medical decision-making.

Determining the level of complexity is complex, but we will do our best to simplify it. Each of these key components hase a subset of elements that determine the extent of the history and examination as well as the complexity of the medical decision-making. 

The extent of the history and exam can be problem-focused, expanded problem-focused, detailed or comprehensive, while the complexity of the medical decision-making can be straightforward, low-complexity, moderate complexity or high-complexity (Table 4).

The type of history depends on the extent of elements obtained during the visit (CC, HPI, ROS, PMHx, PSHx, FHx, SHx). For example, a problem-focused or expanded problem-focused history would only include a single problem with these elements: CC, HPI, +/- ROS (i.e., a patient with a cold). A detailed history would include chief complaint, extended history of present illness, extended review of systes and pertinent past medical, family or social history. (See table 5.)

If you have a patient with three problems (for example, diabetes, hypertension and hyperlipidemia), your documentation for the history component most likely will be detailed enough. Per CMS documentation guidelines , an extended HPI should describe at least four elements of the present HPI or the status of at least three chronic conditions.

The elements of the HPI are the descriptors of a medical problem. Think of the old mnemonic OPQRST (onset, provocative factors, quality/quantity, radiation, severity, timing). For example, the following HPI has four elements and would qualify as an extended HPI.

Since you need to a complete review of systems (more than ten systems) to be able to meet the criteria for a comprehensive history, some clinicians, to get more “points” into the history component, type something like this: “All systems reviewed and negative except for pertinent positives in history of present illness.” or “10/14 review of systems completed and were negative except as stated above in HPI.” These kinds of statements are unnecessary. Is very rare for a clinician to review more than ten systems in a visit. Also, you only need to review two systems to bill a 99214 or 99203. A decent documentation of your HPI most likely will satisfy the requirements for a detailed history.

Most EHRs automatically include some past medical, family and social history into the note, typically in a section different from the HPI. However, it doesn’t matter if the ROS and past history are included in or outside  the HPI section.

 A comprehensive examination involves a general multi-system examination or complete examination of a single organ system. It is fairly easy to document a comprehensive exam using StatNote ’s no-touch exam template, because everything can be gathered from entering the room, greeting the patient and shaking their hand. 

This template covers nine organ systems or elements required for a comprehensive exam. You could then revise the template or add pertinent findings to it.

Medical Decision-Making

We now know that each of the three key components have specific elements that are taken into account to determine the type of history or exam and the complexity of the medical decision-making. Determining the complexity of your decision-making is the most important part of the process since it will ultimately dictate the level of the visit.

The CMS’s Patients Over Paperwork initiative streamlines regulations to reduce burden and increase efficiency. Effective January 1, 2021, practitioners will have the choice to document office/outpatient E/M visits via medical decision-making or time. In other words, if you feel frustrated about all the complexity it takes to determine the type history and exam, in 2021 you will need to focus only on the medical decision-making to determine the level of your visit.

A new patient must meet or exceed all of the three key components required to qualify for a particular level of E/M service, while an established patient must meet only two of the three. (I.e., you could bill for a 99215 for an established patient visit if you documented a complex exam and a high-complexity medical decision, even if your history is just problem-focused. However, to bill for a 99205 for a new patient, you will need all three key components: a complex history, a complex exam and a high-complexity medical decision.)

4. Complexity of Medical Decision-Making

Medical decision-making depends on three elements: 

• The number of diagnoses or management options.
• The amount and/or complexity of data to be reviewed (medical records, diagnostic tests).
• The risk of significant complications, morbidity and/or mortality associated with the patient’s problem(s). 

To reach a level of medical decision-making, two of the three elements must either be met or be exceeded according to the next table of progression.

Indicators of complexity

• Undiagnosed problem > identified problem.
• Number of diagnostic tests. +++ > +
• Problems that are worsening or failing to change as expected > Problems that are improving or resolving.
• Need for a consult from specialist > No need for consult.

That is why coding experts will tell you to document the MEAT for each diagnosis in your note. MEAT stands for the following: 

• Monitor disease progression 
• Evaluate test results or response to treatment
• Assess or address ordering tests, discussion, counseling
• Treatment documentation (medications, therapies).

Since only two out of three elements must be met to reach a MDM level of complexity, let’s focus on the number of diagnoses and risk. For data reviewed, just keep in mind documenting labs or imaging ordered and, if reviewed, comment on the findings (for example, “WBC elevated” or “CXR unremarkable”). Document when medical records were requested and note when history was obtained from sources other than the patient (for example, family, caretaker or other medical records). Also document the relevant information obtained.

The level of risk of complications, morbidity and mortality can be minimal, low, moderate or high. This is based on the risks associated with these categories:

• Presenting problem(s)
• Diagnostic procedure(s)
• Possible management options.

Let’s go through a few examples pertinent to primary care. You can find a more comprehensive table of risks here: CMS documentation guideline (page 18). 

Minimal risk

A patient with a self-limited or minor problem.

• A mosquito bite.
• Patient with a cold managed with rest and gargles.

Acute uncomplicated illness or injury needing over-the-counter drugs.

• Ankle sprain treated with ibuprofen.
• Allergic rhinitis treated with nasal fluticasone spray.

One stable chronic illness.

• Well-controlled diabetes or hypertension.

Two or more self-limited or minor problems.

Moderate-risk

One or more chronic illnesses with mild exacerbation, progression or side effects to treatment.

• Uncontrolled diabetes.
• Patient with hypertension who develops side effects to Amlodipine.

Two or more stable chronic illnesses.

• Visit for diabetes and hypertension.

Acute uncomplicated illness needing prescription drug management.

• UTI treated with antibiotics.
• Dermatitis needing a prescription for topical triamcinolone.

One or more chronic illnesses with severe exacerbation.

An acute or chronic illness that poses a threat to life or bodily function (possibly any patient you see in your office that needs to go to the ED).

• Diabetes with severe hyperglycemia or DKA.
• Patient with neurologic symptoms, needing to r/o stroke.
• Patient with chest pain suspecting MI.
• Patient with RLQ abdominal pain and fever, suspecting appendicitis. 

The AAFP offers this reference card that assigns a point system to each key component-specific element of the medical documentation to ensure that the documentation meets criteria for a 99214 visit. It also details the differences in documentation requirements for level 4 visits with new and established patients.

5. Examples

Now that we understand all the elements that go into determining the appropriate billing code let’s review a few examples of the most common E/M codes. You can go back to table 6 to review the required key components.

Remember that new patient visits require three out of three key components (history, exam, MDM) and established patients only require two out of three. To oversimplify the concept, you could think that a 99213 would be equivalent to a 99202, 99214 equivalent to a 99203, and a 99215 equivalent to a 99204. (See figure 1.)

Progress note 1 – URI

MDM is low: an acute illness treated with over-the-counter drugs. The exam is detailed (even though only an EPF exam is required). The HPI is EPF.

If this was an established patient, it would meet criteria for a 99213 visit. (Check table 6). If this was a new patient, it would qualify only for a 99202 visit. 

99213 – Established patient: Low complexity MDM. EPF history or EPF exam. (only two out of three key components required) .

99202 – New patient: Straightforward MDM. EPF history and EPF exam. (Three out of three key components required) .

It could qualify for a 99203 if you had a detailed HPI, which would require a full past medical, social and family history (which most likely you don’t have since it’s a new patient) and a complete ROS. 

For the sake of argument, let’s say that this is a new patient only because it is new to your department but another doctor in your multi-specialty group has already documented the patient’s medical, social and family history. Assuming that your EHR automatically added all the past medical history to the note (PMHx, FHX, SHx, etc), you would still need to review ten organ systems. In this patient with a common cold, a review of two organ systems would be sufficient (constitutional and respiratory). You could add a complete review of systems to meet criteria for a detailed HPI; however, that would probably be a stretch.

Progress note 2 – DM/HTN/HLD

MDM is moderate complexity: three stable chronic illnesses. The exam is comprehensive. The history is detailed.

99214 – Established patient: Moderate complexity MDM. Detailed history or detailed exam. (only two out of three key components required).

99203 – New patient: Low complexity MDM. Detailed history and detailed exam. (Three out of three key components required).

Even though we have a moderate-complexity MDM in this patient with three chronic problems and we have a detailed history, we cannot bill for a 99204 because we don’t have a comprehensive history.

Progress note 3 – uncontrolled hypertension

MDM is moderate given the moderate risk of complications. In this case, the patient has a chronic condition with mild progression or exacerbation. If it was an hypertension emergency, the MDM complexity would be high given the high risk of complications, morbidity and mortality.

This note would qualify for a 99214 or 99203, depending whether it is an established or new patient.

Progress note 4 – chest pain

MDM is high complexity: an acute illness that may pose a threat to life or bodily function. This patient may be having an MI.

In this and all the previous notes, we used a comprehensive exam. As previously mentioned, you can ensure that you have a comprehensive exam by using a template that you then edit according to your findings. This way you can focus on two key components of your documentation: history and MDM. 

99215 – Established patient: High-complexity MDM. Comprehensive history and comprehensive exam.

99204 – New patient: Moderate-complexity MDM. Comprehensive history and comprehensive exam.

If this was an established patient, even though we don’t have a comprehensive history, we do have a comprehensive exam and high-complexity MDM (2/3).

If this was a new patient, it wouldn’t meet criteria for a 99204 or 99205 visit because you wouldn’t have a comprehensive history. This would require an extensive HPI, a complete ROS and complete past medical history. However, if you spent 45 minutes or more with the patient you could bill based on time as long as you document something along these lines:

Total encounter time was 45 minutes with more than 50 percent of the visit involved in counseling/coordination of care. An EKG revealed ischemic changes and an ambulance was called, EMS took the patient to the ED and I personally discussed the case with the ED physician.

6. Other billable services

Other services you can bill for include the following:

• Preventive medicine services
• Counseling services
• Nursing home visits
• Home visits
• Telephone services
• Telehealth visits
• Online medical evaluation
• Work-related or medical disability exams
• Care plan oversight
• Cognitive assessments
• Chronic care management services
• Transitional care management services
• Advance care planning

Don’t limit yourself to billing only for 99213s and 99214s. In our next article, we will explore all your options. Chances are that you are already providing some of these services, but you might not be documenting or billing for it.

You can also find more dot phrases and commonly used CPT codes in our book. Get it today for free on Amazon using kindle unlimited.

Final Thoughts

Don’t forget to subscribe to our blog and our YouTube channel for interesting articles and videos.

What other billing and coding tips do you use? Feel free to share. Comment below.

Discover Chartnote – We are passionate about preventing physician burnout by decreasing the burden of medical documentation.

About Chartnote

Chartnote is revolutionizing medical documentation one note at a time by making voice-recognition and thousands of templates available to any clinician. We know first-hand that completing notes while treating patients is time-consuming and an epic challenge. Chartnote was developed as a complementary EHR solution to write your SOAP notes faster. Focus on what matters most. Sign up for a free account:  chartnote.com

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Don’t limit yourself to billing only for 99213s and 99214s. In our next article, we will explore all your options (where is the link for the next article?). Thanks.

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September 4, 2024

CMS Update on Medical Record Documentation for E/M Services

The world as we knew it

Summary of changes described in this article

In 2018, CMS changed the requirements for using medical student E/M notes by the attending physician. In the 2019 Physician Fee Schedule Final Rule, CMS stated its desire to reduce the burden of documentation on practitioners for E/M services, in both teaching and non-teaching environments. They stated that a clinician no longer had to re-document the history and exam, but could perform those and “review and verify” information entered by other team members, or entered in prior notes. In 2019, CMS updated the section of the Medicare Claims Processing Manual that addressed E/M services in teaching settings, allowing a nurse, resident or the attending to document the attending’s presence during an E/M service. In 2020, CMS made a radical change to documentation requirements, adopting this as a policy,

“Therefore, we proposed to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team.” [1]

• CMS has made significant changes in E/M notes to reduce burden on practitioners in the past years.
• CMS is now allowing clinicians to “review and verify” rather than re-document the history and exam. The details are below.

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“Copy-Pasting. Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.” [2]

Read the OIG report

CMS responded that it agreed that additional guidance was needed and that it intended to work with its contractors in the development of effective guidance. To my knowledge, that guidance was never released.

• The OIG expressed concern about copy/paste and over-documentation in 2014, but this did not lead to CMS standards about the practice.
• Commercial payers are largely silent, as well.

2019 Easing the burden of documentation

“We proposed to expand this policy to further simplify the documentation of history and exam for established patients such that, for both of these key components, when relevant information is already contained in the medical record, practitioners would only be required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history. Practitioners would still review prior data, update as necessary, and indicate in the medical record that they had done so. Practitioners would conduct clinically relevant and medically necessary elements of history and physical exam, and conform to the general principles of medical record documentation in the 1995 and 1997 guidelines. However, practitioners would not need to re-record these elements (or parts thereof) if there is evidence that the practitioner reviewed and updated the previous information.” [3]

That long-winded paragraph says that a practitioner would not need to re-record history and exam for established patients that they had reviewed and verified from a prior note.

This was verified by a letter from CMS head Seema Verma . Ms. Verma’s letter went further. It said that effective 1-1-2019, not only could the clinician review and verify history and exam, but for both new and established E/M services, specifically,

“Clarify that for both new and established E/M services, a Chief Complaint or other historical information already entered into the record by ancillary staff or patients themselves may simply be reviewed and verified rather than re-entered” [4]

• In 2019, CMS said that for a new or established patient, the billing clinician could “review and verify” information entered into the record by ancillary staff or patients, rather than re-document.
• CMS included “history and exam” as components that could be reviewed from prior entries and verified, not re-documented.
• Section from 2019 rule and letter from Ms. Verma attached to this article

2020 Expanded “Review and verify”

Perhaps the most shocking change came in the Physician Fee Schedule Final Rule in 2020. CMS noted that stakeholders were questioning whether “students” described in the Medicare claims processing manual referred only to medical students, or if that also referred to nurse practitioner and physician assistant students. Advanced practice registered nurses (APRNs) and physician assistants (PAs) told CMS that they wanted to use the same rules for precepting their students as physicians used when precepting medical students. CMS agreed with them. But, they went farther.

“Therefore, we proposed to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. We explained that this principle would apply across the spectrum of all Medicare-covered services paid under the PFS. We noted that because the proposal is intended to apply broadly, we proposed to amend regulations for teaching physicians, physicians, PAs, and APRNs to add this new flexibility for medical record documentation requirements for professional services furnished by physicians, PAs and APRNs in all settings.” [5]

Read that section in it’s entirety

• In the 2020, CMS established a general principal to allow the physician/NP/PA to review and verify information entered by physicians, residents, nurses, students or other members of the medical team.
• This principle applies broadly for professional services furnished by a physician/NP/PA.

Codes 99202–99215 in 2021, and other E/M services in 2023

In 2021, the AMA changed the documentation requirements for new and established patient visits 99202—99215. Neither history nor exam are required key components in selecting a level of service. This further reduces the burden of documenting a specific level of history and exam. The 2021 CPT book says this regarding history and exam.

“The care team may collect information and the patient or caregiver may supply information directly (eg, by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of office or other outpatient services.” [6]

• In 2021, for visits reported with codes 99202—99215, history and exam will not be used to select the level of E/M services. This framework was extended to other E/M services in 2023.

What about teaching physicians

CMS began changing the teaching position rules in 2018, with the stipulation about student documentation. The citation from the CMS manual that changed is below.

B. E/M Service Documentation Provided By Students

“Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.” [7]

What this says is the teaching physician must still do the work. But, the teaching physician doesn’t have to re-document the work. It saves re-documentation on the part of the attending, in the same fashion as the attending doesn’t need to re-document all of the resident’s work.

Documentation performed by medical students, advance practice nursing students and physician assistant students:

“Therefore, we propose to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the PFS.”

• Now, physician assistant and nurse practitioner students are treated the same way as medical students for documentation purposes.
• Any physician or NPP who bills a service can “review and verify” rather than re-document.
• Includes “information included in the medical record by physicians, residents, nurses, students or other members of the medical team.”

The new rules allow the attending, the resident or the nurse to document the attending’s participation in the care of the patient when performing an E/M service. CMS said they were going to do this in the 2019 Physician Fee Schedule Final Rule, released in November of 2018, but the transmittal wasn’t released until April 26, although there is an effective date of January 1, 2019 and an implementation date of July 1, 2019. The transmittal does not include any of the examples of linking statement that were in the manual for so many years. It is brief—here is the section on E/M.

100.1.1 – Evaluation and Management (E/M) Services (Rev. 4283, Issued: 04- 26-19, Effective: 01-01-19, 07-29-19) A. General Documentation Requirements

Evaluation and Management (E/M) Services – For a given encounter, the selection of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Association’s Current Procedural Terminology (CPT®) book and any applicable documentation guidelines.

For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:

• That the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
• The participation of the teaching physician in the management of the patient.

The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.

These are significant changes for all practices, including those in academic settings. We hope that our MACs are paying attention to CMS’s intentions and that other payers follow suit.

[1] CMS 2020 Physician Fee Schedule Final Rule

[2] CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs, January 2014 OEI-01-11-00571.

[3] CMS 2019 Physician Fee Schedule Final Rule, page 572

[4] CMS letter from S. Verma, 2019

[5] 2020 Physician Fee Schedule Final Rule, p. 380

[6] AMA, CPT E/M codes, 2021

[7] Medicare Claims Processing Manual, 100-04, Chapter 12, Section 100

Last revised May 21, 2024 - Betsy Nicoletti Tags: compliance issues

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Coding tips: Level 3 vs. 4 evaluation and management

To payers, these visits tell a completely different story about the work that’s required to treat a patient.

The difference between a level 3 and level 4 office visit might not seem like much, but to payers, these visit types each tell a completely different story about the work that’s required to treat a patient.

When physicians report a level 4 evaluation and management (E/M) code, they’re telling payers they should be paid more because their patient requires medical management for an exacerbation of an existing chronic condition, a complication, or a new problem, says Raemarie Jimenez, CPC, vice president of membership and certification solutions at AAPC in Salt Lake City, Utah. Payers may deny level 4 E/M codes for patients who respond well to treatment and are generally well-managed, she adds.

When using an EHR, though, it’s easy for physicians to default to a level 4 E/M code that might not be justified, says Jimenez. That’s because the EHR pulls information forward that might not be clinically relevant or even pre-populates information that falsely inflates the actual work the physician performs. “The computer just picks up on keywords and boxes, but it’s not smart enough to realize that a visit might be over-documented,” she adds.

For example, pulling information forward, such as a comprehensive family history or a complete review of systems, can inadvertently drive a level 4 E/M code when the nature of the presenting problem (e.g., otitis media) in no way supports this level of service, explains Jimenez. Over time, it may appear to payers that a physician is upcoding as compared to peers.

To avoid payer scrutiny, Jimenez advises physicians always to ask themselves these three questions before assigning a level 4 E/M code:

1. Is this patient sicker than most of the patients I see? 2. What specifically elevates the level of effort that’s required to treat this patient? Have I documented this information in the record? 3. Have I reported the most specific ICD-10-CM diagnosis code to justify patient severity?

Physicians should also know whether their EHR might be putting them at risk for upcoding. Jimenez says to consider these three questions:

1. Does the EHR auto-populate information and require physicians to deselect what’s not pertinent to the visit? For example, an EHR might auto-populate a complete review of systems and require physicians to deselect the systems they don’t review with the patient. This practice is extremely risky because physicians don’t often remember to review the information or they may simply forget to deselect it, says Jimenez. Best practice is for physicians to manually select what they want to bring forward. It shouldn’t happen automatically, she adds.

2. Do diagnosis-specific templates require physicians to perform certain tasks every time they see a patient? All work must be clinically relevant, says Jimenez. “Physicians shouldn’t be forced to do something just because the EHR is telling them to do it. Everything they do should be based on their own clinical judgment.”

3. Does the EHR require physicians to bill a certain code? The code that the system calculates may not be accurate, and physicians always need the ability to override it when necessary, says Jimenez. She provides the example of a physician who includes rule-out diagnoses for continuity-of-care purposes. If the physician isn’t actively managing these conditions, they shouldn’t be counted toward the visit’s E/M level. If the EHR gives credit for this information, physicians need to recognize that the E/M level may be inflated, and they should override the code manually, she says.

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Office Visits- E&M codes in Medical Billing

• June 3, 2024
• E & M codes in Medical Billing

For the office visits – E&M codes in Medical Billing, doctors can now code visits only for the whole period, which is defined as the entire amount of time you spent caring for the patient on the visit date. It covers patient history, clinical examination, in-person meetings with the patient, providing the patient or family with a call, and medical decision-making, which are critical components for determining the accurate code level. It excludes the time you spend with your nurses or other staff members, the time you spend on different days, and the time you spend doing remedies billed by themselves.

What are E&M Codes in Medical Billing?

A group of Clinical Procedural Terminology (CPT) codes are owned by doctors and other practitioners who accept payment under the Medicare Physician Fee Schedule (MPFS) to bill or Medical billing Service for efficient office or outpatient visits for evaluation and management (E/M) services.

Evaluation and management codes related to E&M codes or E and M codes are a coding system that uses CPT Codes from the range 99202 to 99499 representing services including Best Medical coding company given by a physician or other qualified healthcare professional, which describe medical services provided by a doctor or other certified clinician. Preventive health services, home services, hospital visits, and office visits are a few characteristics of E&M codes.

What Does Healthcare E&M indicate?

Physician and provider services that are more concerned with patient meetings, physical examinations, and medical decision-making than with testing and procedures are denoted by E&M (Evaluation and Management) codes.

E&M Coding’s Importance in Healthcare

To pay medical personnel for the time and effort they spend caring for patients, using E&M codes is an essential phase of Best medical billing services. These codes determine the satisfaction level for the time and effort healthcare professionals spend assessing and managing a patient’s care. Correct coding is essential to avoid underbilling, which results in lost revenue, or overbilling, which can lead to checks, fines, and legal costs.

E/M Codes: The Basics of Medical Billing

E/M codes are the basis of Medical billing services for small practices in hospital and outpatient settings. These are the most frequently utilized codes, and their use significantly affects healthcare providers’ revenue cycle management. Accurate E/M coding guarantees that healthcare providers receive fair payments for the time and complexity of patient care.

Standards for EM Coding: Documentation

Proper documentation is the core of E&M coding. The EM coding suggestions and the cost of medical billing services emphasize the necessity of correct and thorough medical records. Healthcare professionals must keep track of the patient’s medical history, examination results, and decision-making procedures in a way that supports the selected E&M code.

Rules for E&M (Evaluation and Management) Coding

These rules provide a regular approach to choosing the correct E&M code, depending on many variables, such as the level of evaluation intensity, the difficulty of medical decision-making, and the type of care location, such as a hospital, outpatient clinic, or private office.

Significance of E/M in the System of Care for Patients

The meaning of E/M in the context of patient care expands beyond medical billing and coding services. It displays the standard and scope of the medical care given. When E&M codes are correctly used, patient care is properly recorded and paid for, supporting the long-term health of medical treatments and the healthcare system as a whole.

Principles for Evaluation and Management: Complexity and Setting

E&M services are split into levels that reflect the degree of medical decision-making intensity, from simple to highly complex, based on the complexity of patient care. The treatment setting is also crucial when selecting a code. Different codes apply to services provided in hospital settings related to outpatient settings.

Significant Instructions for E&M CPT Codes

Physicians use E&M CPT codes to bill for Premium billing services and get paid. Doctors and coders need to be aware of the rules to accurately select the correct E&M codes for the service. The following list of important variables will help you understand the rules more fully when choosing suitable assessment and management codes.

Making Medical Decisions (MDM)

The MDM process uses physicians’ daily skills and training to help them make the best decisions for their patients. Medical coding and billing Services often use MDM to justify the use of definite coding levels.

• Independent assessment interpretation.
• Testing results, records, directives, or separate medical histories.
• The quantity and complexity of issues discussed during an interaction.
• There are four known varieties of MDM: high, moderate, low, and plain.
• The volume of information to be examined. Test results, medical records, and other details that can be studied before, during, or after the contact are examples of data.
• Risk of complications from patient management decisions made during the visit linked to the patient’s condition, diagnosis, or course of treatment because of the seriousness or death of the patient.

The right evaluation and management of CPT codes by Medical billing and coding experts determine the duration of the communication on the meeting date, whether in part or whole. This can include time spent personally by the doctor, both in person and online, and it can consist of the following:

• Case management  (not separately reported)
• Making an order for drugs, exams, or surgeries
• Examining history that was obtained separately
• Conducting an evaluation or test that is legally required
• Prepared to see the patient ( For example, tests, reviewed)
• Adding clinical data in the electronic medical record or other
• Sending patients to and engaging with other medical experts (when not recorded individually)

It eliminates travel time, time spent on procedures that are not being billed, and teaching unrelated to that specific patient.

Bottom Lines

We conclude that E&M CPT codes are essential to healthcare billing and coding.  Understanding what E&M codes are, adhering to E&M coding guidelines, and appreciating the refinement of evaluation and management guidelines are necessary for proper and efficient healthcare billing. If you are an office-based physician, you should understand what E&M is in healthcare, the coding guidelines for evaluation, and Medical billing management services. E&M medical coding services represent an essential part of patient care, and the correct application of E/M codes ensures that this care is perfectly captured and reimbursed.

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CPT Office Visit Codes: A Quick Reference Guide

Table of Contents

When it comes to medical billing and coding, accurate documentation and coding of office visits is crucial for healthcare providers. This is where CPT office visit codes come into play. CPT, which stands for Current Procedural Terminology, is a system developed by the American Medical Association (AMA) to standardize the reporting of medical procedures and services. In this article, we will delve into the importance of understanding CPT office visit codes and provide you with a comprehensive quick reference guide.

Understanding CPT Office Visit Codes

CPT office visit codes are used to classify and bill for face-to-face encounters between healthcare providers and patients in an office setting. These codes help determine the appropriate level of reimbursement based on the complexity and intensity of the visit. Understanding CPT office visit codes is essential for accurate and efficient medical billing and coding.

CPT office visit codes are categorized into different levels, ranging from level 1 (lowest complexity) to level 5 (highest complexity). The codes take into account various factors such as the nature of the presenting problem, history and examination performed, and the complexity of the medical decision-making involved. It is crucial for healthcare providers to accurately document and code each office visit to ensure proper reimbursement and to provide a clear record of the patient’s medical history.

A Comprehensive Quick Reference Guide

To help healthcare providers navigate through the complexity of CPT office visit codes, we have put together a comprehensive quick reference guide. This guide outlines the key elements that should be considered when coding office visits and provides examples for each level of complexity. It also includes documentation requirements and tips to ensure accurate coding and billing.

The quick reference guide begins by explaining the different levels of CPT office visit codes and their corresponding complexity criteria. It then provides an overview of the documentation requirements for each level, including the necessary history, examination, and medical decision-making components. Additionally, the guide offers helpful coding tips and common pitfalls to avoid when coding office visits.

Accurate coding of office visits is crucial for healthcare providers to receive appropriate reimbursement and ensure compliance with billing regulations. The use of CPT office visit codes streamlines the billing process and provides a standardized framework for reporting medical services. By understanding the nuances and requirements of CPT office visit codes, healthcare providers can ensure proper documentation and coding, resulting in accurate reimbursement and a clear record of the patient’s medical history. Utilizing a comprehensive quick reference guide can greatly assist in this process, helping healthcare providers navigate the complexities of CPT office visit codes effectively.

What are CPT Office Visit Codes, and why are they important in medical coding ?

CPT Office Visit Codes are a set of Current Procedural Terminology codes specifically designed to represent various types of patient encounters in an office setting. These codes play a crucial role in medical coding as they help define and categorize the complexity and nature of office visits, aiding in accurate billing and reimbursement.

How are CPT Office Visit Codes structured, and what do the different levels (e.g., 99201-99215) signify?

CPT Office Visit Codes are structured into different levels, typically ranging from 99201 to 99215. These levels signify the complexity of the office visit, taking into account factors such as the extent of the history, examination, and medical decision-making. Higher-level codes represent more complex and comprehensive visits.

What criteria should healthcare providers consider when selecting the appropriate CPT Office Visit Code for a patient encounter?

Healthcare providers should consider factors such as the patient’s history, the extent of the physical examination, and the complexity of medical decision-making. The documentation should support the level of service provided during the office visit to ensure accurate code selection.

How do CPT Office Visit Codes impact reimbursement, and why is it important for healthcare providers to accurately assign these codes?

CPT Office Visit Codes directly influence reimbursement, as they are used by payers to determine the appropriate payment for services. Accurate code assignment is crucial for healthcare providers to receive fair compensation for the level of care provided during office visits and to avoid potential billing errors.

Are there specific documentation requirements that healthcare providers should follow when using CPT Office Visit Codes?

Yes, there are specific documentation requirements for each level of CPT Office Visit Code. Providers should ensure thorough documentation of the patient’s history, examination findings, and medical decision-making. Clear and detailed documentation supports the assigned code and helps in justifying the level of service provided.

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Telehealth and Remote Patient Monitoring

Billing for remote patient monitoring.

Learn about policies and reimbursement for remote patient monitoring (RPM).

On this page:

What remote patient monitoring services are billable, private insurance, safety net providers.

RPM includes both remote physiological monitoring and remote therapeutic monitoring .

• Remote physiologic monitoring involves the use of non-face-to-face technology to monitor and analyze a patient's physiological metrics. Examples of physiological metrics include oxygen saturation, blood pressure, blood sugar or blood oxygen levels, weight loss or gain.
• Remote therapeutic monitoring (RTM) captures non-physiologic data related to a therapeutic treatment. This includes data on a patient’s musculoskeletal or respiratory system. RTM can also monitor treatment adherence (e.g., medication compliance) and treatment response (e.g., pain management). Information is transmitted using a connected medical device.

Both remote physiologic monitoring and remote therapeutic monitoring data can be transmitted electronically; however, only RTM data can be self-reported by the patient using the device.

Medicare reimburses for both remote physiological monitoring and RTM.

Requirements for RPM include:

• Remote physiologic monitoring, but not RTM, requires an established patient relationship.
• Remote physiologic monitoring service must monitor an acute or chronic condition.
• 16-day data collection in a 30-day period does not apply to treatment management codes 99457, 99458, 98980, and 98981.
• Only one practitioner can bill for RPM per patient in a 30-day period.
• Remote physiologic monitoring and RTM cannot be billed together.
• Monitoring must be medically reasonable and necessary.
• Remote physiologic monitoring and RTM, but not both, may be billed concurrently with the following care management services for the same patient as long as time and effort are not counted twice: chronic care management (CCM), transitional care management (TCM), behavioral health integration (BHI), principal care management (PCM), chronic pain management (CPM).
• For global periods of surgery, remote physiologic monitoring and RTM may be billed by practitioners that are not receiving the global service payment.
• Patient consent is required at the time RPM is furnished.
• Physiologic data must be electronically collected and automatically uploaded to a secure location where the data can be available for analysis and interpretation by the billing practitioner.
• The device used to collect and transmit the data must meet the definition of a medical device as defined by the FDA .
• The services may be provided by health care personnel under the general supervision of the billing practitioner.

Medicare policies for telehealth  continue to evolve. For the latest information, view the Medicare Physician Fee Schedule . The following Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes are frequently used to bill for RPM services. Coding guidance is subject to change.

Each state has its own billing and reimbursement policies. For tips on Medicaid policies, visit Medicaid and Medicare RPM .

Find out if the patient has private insurance. If so, check with the patient's insurance company for information on their billing and reimbursement policies. For tips on private insurance policies, look up policy by jurisdiction .

RPM services are billable. Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can receive a separate payment for these services.

Requirements include:

• An established patient relationship
• Patient consent at the time RPM is furnished
• Must be medically reasonable and necessary
• Must not be duplicative

Tip: Read more about billing Medicare for telehealth services as a safety net provider .

More information:

Leveraging Remote Patient Monitoring in Your Practice (PDF) — Health Resources and Services Administration

Billing and payment policies for telehealth services to treat chronic conditions  — Health Resources and Services Administration

Medicare Learning Network: Chronic Care Management Services  — Centers for Medicare & Medicaid Services

Telehealth for Providers: What You Need to Know (PDF) — Centers for Medicare & Medicaid Services

Remote Patient Monitoring Policy  — National Telehealth Policy Resource Center

Tucson woman concerned after her ‘free’ annual physical generated a bill

TUCSON, Ariz. (13 News) - A Tucson woman says she was blindsided by a recent medical bill. She went for a free annual checkup – but says the doctor billed for more.

Sue Burd recently saw an OB/GYN for her ‘well woman’ exam. It’s a preventative wellness visit that happens every year, and it’s supposed to be free under her insurance.

“I called and I said I think there’s been a mistake. I said I got a bill for my well woman exam, and this is a free exam. And she looked it up and said no there’s no mistake. When you get a bill, it’s because you spoke about your prescription during your well woman exam,” said Burd. “And I was kind of shocked by that.”

Shocked, because all she did was ask for a prescription refill during the wellness visit.

By doing that, she says it triggered an additional office visit charge – a $30 bill she is expected to pay.

“Very disappointing, very disappointing,” said Burd.

She tried to dispute it with Genesis OB/GYN Northwest but says her calls haven’t been returned.

Where does it stand now?

“I still owe the $29 and change. It’s not that I can’t afford it. It’s just that I think there should have been some disclosure to let me know, hey if you’re going to ask about something other than your well woman exam we’re going to charge you and we’re going to bill your insurance company differently,” she said.

13 News reached out to Genesis with Burd’s permission to ask whether the wellness visit was billed incorrectly, if they’re willing to work with Burd to share the cost, or resubmit the claim.

A billing department spokesperson told us they’re unable to comment but said she’d pass along our request for answers.

We also emailed the practice manager directly. It’s been 10 days, and no one has gotten back to us.

“Having been a patient there for over 20 years I never expected this to happen because it’s never happened before,” said Burd.

Burd posted about it on Nextdoor, she says, to educate others.

To date, it’s received more than 230 comments and interactions. Many people are sharing similar stories about healthcare visits and billing concerns at various doctors offices.

”A free preventative simply means it is covered by your healthcare at zero co-pay, zero co-insurance deductible,” said Beth Schleeper who owns an Arizona based billing and coding firm called TNT Consulting , and a medical school called Advanced Coding Services .

She’s not involved with either party in this case.

Schleeper says writing prescriptions, even refills, is a separate service from an annual wellness visit – and the doctor is entitled to bill for it.

Do you think physicians can do a better job at explaining things to patients in the moment, or are most providers doing a good job already?

“Well, I’m going to say it’s probably not up to the physician to explain the billing services or coding criteria to the patient. It’s probably up to the front desk people. Hey, you’re here for your well woman, your well man, your annual visit. Anything beyond the scope of that is probably going to be a separate billable item,” said Schleeper.

Schleeper recommends calling your insurance prior to scheduling a wellness visit so you understand what’s free and what’s not. If you receive an unexpected bill, question it.

“So, I could file an appeal. But at this point I’m concerned I’ll get sent to collections. I’ll probably have to pay for it and then go from there,” said Burd.

Looking back, Burd wishes she would have just called the office to request the refill to avoid the charge.

Bottom line, not all care that might be provided during a wellness visit counts as no-cost preventive care.

But don’t be afraid to ask about health concerns you might have. Schleeper says if time allows, the doctor may decide to have the conversation that day – or offer to schedule a separate appointment to address it.

Be sure to subscribe to the 13 News YouTube channel: www.youtube.com/@13newskold

Copyright 2024 13 News. All rights reserved.

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Got an unaffordable or incorrect medical bill? Calling your hospital billing office will usually get you a discount

What do you do when you disagree with or can’t afford a medical bill?

Many Americans struggle to pay medical bills, avoid care because of cost worries or forgo other needs due to health care cost burdens.

It can be hard to understand what you’re being charged for on a medical bill. I’m a health policy and economics researcher who studies insurance and out-of-pocket health care expenses, and even I sit at my kitchen table trying to wrap my head around bills and explanations of benefits.

In my newly published research, I surveyed a nationally representative sample of 1,135 American adults – a subset of participants from the University of Southern California’s Understanding America Study – to find out how they handle troubling medical bills. I learned that advocating for yourself can pay off when it comes to medical bills, and you may be missing out on financial relief when you don’t pick up the phone.

Squeaky wheel gets the grease

My team and I found that 1 in 5 patients had received a health care bill in the prior year that they disagreed with or couldn’t afford. Nearly 35% of the bills came from doctor’s offices, nearly 20% from emergency rooms or urgent care and over 15% from hospitals. Other sources of bills included labs, imaging centers and dental offices.

A little over 61% of respondents contacted the billing office about a troubling bill, but 2 in 5 did not. Why not? About 86% of patients said they did not think it would make a difference.

But reaching out got results . Nearly 76% of patients who reached out got financial relief for an unaffordable bill. Nearly 74% who spoke up about a potential billing mistake received bill corrections. For those who negotiated their bills, nearly 62% saw a price drop.

Additionally, 18% of patients who reached out got a better understanding of their bill, 16% set up payment plans and a little over 7% got the bill canceled altogether. Nearly 22% said their issue was unresolved, and 24% reported no change.

The majority of people who reached out about their medical bills reported that it took less than one hour to handle their issue.

Picking up the phone

We found that people with a more extroverted and less agreeable personality – based on the Big Five Personality Test – were more likely to reach out about a medical bill. People without a college degree, with lower financial literacy or with no health insurance were less likely to reach out to a billing office.

Differences in who does and doesn’t call about a medical bill may be exacerbating inequalities in how much people end up paying for health care and who has medical debt.

Many Americans are in health plans with high out-of-pocket cost sharing , including high-deductible plans . This so-called consumer-directed health care paradigm is intended to motivate consumers to be more cost-conscious when seeking care and navigating their bills. But by design, it puts the burden on patients to deal with billing issues.

Another recent study my team and I conducted found that 87% of U.S. hospitals offer their own payment plans, but only 22% of these put plan details on their websites. You have to call for more information.

In another recent study, my team called hospitals as “secret shoppers ” planning an elective knee surgery. We sought information critical to assessing affordability: financial assistance, payment plans and payment timing options. While the information was often available, it was hard to access. We couldn’t reach a representative with information at about 18% of hospitals, even after calling on three different days. We were typically directed to three different offices to get all the information we wanted.

Policymakers have made strides in price transparency in recent years. For example, hospitals are required to post prices for their products and services. Practices and policies that further reduce the administrative burden of accessing aid and navigating troubling bills.

Pro tip: Make the call

Patients who make the call are benefiting when it comes to medical bills.

A colleague who knew I was working on this study asked me for advice about a $425 bill her household had received for a lab test at an urgent care center. The bill seemed inflated and unfair, forcing an unexpected stretch to her budget.

I told her it was worth a call to the billing office to express her feelings about the bill and see whether any adjustments could be made to the amount owed or the timing of payment.

It was worth the call. The billing office representative offered three options on the spot: a.) a payment plan, b.) a prompt payment of $126 paid immediately over the phone to settle the account, or c.) financial assistance if eligible based on income.

My colleague chose option b and paid less than one-third of the original bill amount.

The next time you get a medical bill that troubles you, pick up the phone or ask a disagreeable extrovert to make the call for you.

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Erin Duffy receives funding from Arnold Ventures and provides expert testimony on matters in the health insurance and hospital sectors.

How to Code for Telehealth, Audio-Only, and Virtual-Digital Visits 

Learn how to accurately get paid for telemedicine services with medical codes for telehealth, audio-only, and virtual-digital visits.

Looking for additional telemedicine coding resources?

Coding for Telehealth Visits

Note:  These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments. 

How do I code a new or established patient telehealth office visit that uses audio-video communications technology?

* Elevance's  policies vary by state; contact your provider-relations representative.

Coding for Audio-only Visits

How do i code an audio-only visit for a new or established patient .

CPT Codes: 99441-99443 

Audio-only scenario notes 

Medicare requires audio-video for most office visit evaluation and management (E/M) services (CPT codes 99202-99215) telehealth services. Audio-only encounters are allowed for certain services. Eligible services may be found on the Medicare Telehealth Services list. Medicare allows audio-only telehealth services for office visit E/M services (CPT codes 99202-99215) for the treatment of mental health conditions.   

UHC states they will consider payment for eligible audio-only services listed in Appendix P of the CPT book. Eligible services must be reported using either POS 02 or 10 and include the -93 modifier. CPT codes billed with modifier -93 that are not in Appendix P will not be considered for payment.   

Private payers vary on covered telehealth services. Check with your provider relations representatives for each payer’s telehealth policy and covered telehealth services. 

CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443) through the end of calendar year 2023. Other services that may be provided via audio-only are available on the Medicare Telehealth List. 

Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment. 

The following codes may be used by physicians or other qualified health professionals who may report E/M services: 

• 99441: telephone E/M service; 5-10 minutes of medical discussion 
• 99442: telephone E/M service; 11-20 minutes of medical discussion 
• 99443: telephone E/M service, 21-30 minutes of medical discussion 

Telephone E/M services should not be reported when the time spent on the telephone is captured in other services reported, such as: 

• if CPT codes 99421-99423 have been reported by the same physician in the previous seven days for the same problem, 
• when CPT codes 99339-99340 and 99374-99380 are used for the same call, 
• during the same month with CPT codes 99487 and 99489, and 
• when performed during the same service period at CPT codes 99495-99496. 
• Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies.  

Coding for Virtual-Digital Visits 

How do i code an e-visit (cpt 99421-99423) for an established patient .

CPT Codes: 99421-99423 

How do I code a virtual check-in (HCPCS codes G2012 and G2010) for an established patient? 

HCPCS Codes: G2012, G2252, G2010 

Virtual/Digital Scenario Notes 

• Patient consent is required and may be obtained either before or at the time of service. 
• Virtual check-ins and e-visits must technically be initiated by a patient; however, physicians and other providers may need to educate beneficiaries on the availability of the service prior to patient initiation. 
• There are no POS or modifier requirements for virtual check-ins or e-visits. Use the POS used for typical services. 

Virtual Check-in (HCPCS Code G2012, G2252) 

• These are brief conversations with a physician or other clinician to determine if an in-person visit is necessary. 
• The communication cannot be related to a medical visit within the previous seven days and cannot lead to medical visit within the next 24 hours (or soonest appointment available). 
• Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal. 
• HCPCS code G2010 can be used when a captured video or image (store and forward) is sent to the physician. The physician must follow up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment). 

E-Visits (online digital evaluation and management services) 

• These are non-face-to-face, patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period, and the exchange must be stored permanently. 
• Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans (including generation of prescriptions or ordering of tests), and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication 

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes:

• 99421: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 
• 99422: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes 
• 99423: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 

E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient. Additionally, e-visits should not be billed when using the following codes for the same communication: 

• 99339-99340 
• 99374-99380 
• 99487 and 99489 
• 99495-99466 

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