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.
#Office visits how to
How to Determine Level of Complexity of a VisitĪs mentioned earlier, three key components of your documentation determine the E/M service level for an outpatient visit: history, exam and medical decision-making.
#Office visits code
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. 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. Some clinicians could be tempted to bill based on time for all their visits so they can bypass all the onerous medical documentation requirements.
#Office visits professional
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. However, most clinicians spend some time before the visit reviewing the chart and after the visit completing the visit note. 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.įace-to-face time, for documentation purposes, is the actual time spent with the patient. 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. There are several elements of medical documentation, but the key components are history, exam and medical decision-making (Table 2). 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 9923 if it is a new patient.
Several components of your documentation are used to define the level of the visit or E/M service you provide. 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. 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.
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. When billing for an outpatient visit, you need to know whether you have a new or an established patient.
Medical billing and coding is not taught in medical school and is only briefly reviewed during residency training. However, when it comes to medical billing, payers might not be able to differentiate between innocent mistakes and deliberate missteps. 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. Many leave money on the table and “undercode” for fear of being flagged or audited by CMS or commercial payers. 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.
Should you use 99213 or 99214 for your patient visit?
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