Introduction of 99213 CPT Code:
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Summary of 99213 CPT Code:
Office or other outpatient visit codes are typically reported daily and are differentiated as new or established patients. There are five levels of office and other outpatient codes category represented by 99211-99215.
These codes report office or other outpatient services for only established patients. CPT code 99213 is the low-level Medical decision-making E&M code and includes straightforward decision-making.
According to medical coding and billing guidelines, An Established patient has received professional services from a physician, another physician, or other qualified healthcare professionals of the same specialty or subspecialty and belongs to the same practicing group within the past three years.
Codes from CPT 99211–99215 should be selected based on the current CPT Medical Decision-Making table. Alternatively, time alone may be used to determine the appropriate level of service. Total time for reporting these services includes face-to-face and non-face-to-face time personally spent by the Doctor or other health care professionals on the date of the encounter.
When using time for code selection, 99213 is selected when doctors spend 20-29 minutes on a patient’s evaluation and management.
The treating provider should document a medically appropriate history and physical examination. The right level of history and physical examination is no longer used when determining the level of service and is only used to make the level of E&M codes.
Providers report this CPT 99213 for established patients being seen in the Doctor’s office, a multispecialty group clinic, or other outpatient environments. Furthermore, CPT 99213 is the basic service, which entails Low-Level MDM with minor conditions. Using time for code selection of CPT 99213, 20-29 minutes of the total time should be spent on the date of the encounter.
Key points to remember
The critical elements of service of E/M are:
- History
- Examination
- Medical decision-making.
You only need to take a complete history or physical exam to choose the level of Evaluation and management service level based on time if it is medically necessary. If a patient is returning to discuss the report findings of a test you ordered at a previous visit, you don’t need to repeat an entire history and exam at the current visit. Only document the total time of the visit and the time doctor has spent in counseling or coordination of care activities.
Description of 99213 CPT Code:
99213 -Office or other outpatient visits for an established patient (Evaluation & management) requires a medically appropriate history, examination, and Low-level (Medical decision-making). When selecting the level of E&M code, it should be between 20-29 minutes spent on the date of the encounter.
Selection Criteria of 99213 CPT Code:
The proper level of E/M services for established patients is based on the criteria mentioned below.
History– Expanded problem-focused
Exam —-Expanded problem-focused
MDM — Low level
Two critical components must be fully documented to bill (other than 99211) when billing office or other outpatient services.
All the confronting and non–confronting time spent by the clinician on the day of the visit should be counted. Counseling should never be more than 50% of the total time.
Documentation Tips:
Even if a complete medical note is generated, only the essential services for the patient’s condition should be considered in determining the level of an E/M code at the time of the visit.
Medical necessity must be clearly stated and support the level of service reported.
Reimbursement Tip:
The place-of-service (POS) codes for reporting these services are the same as those for a new patient: POS code 11 represents the clinician’s office environment, and POS code 22 means the outpatient setting.
When a separately identifiable E/M service is reported simultaneously as another procedure, modifier 25 should be used with the E/M service to indicate the service is distinct from the other service performed.
Billing Guidelines:
Only one unit per visit of CPT 99213 is allowed to be billed.
Modifiers change the price and nature of the medical procedure, service, or supply involved without changing the meaning of the code.
Modifiers allowed with CPT 99213 are given below:
24, 25, 27,33, 57,93, 95, 99, AI, AQ AR, CC, CR, CS, ET, EY, FR, G0, GA, GC, GE, GT, GU, GY, GZ, KX, Q5, Q6, QJ, TH.
The most commonly used modifiers with CPT 99213 are 25, 57, 95, and GT.
Example:
An established patient presented to his family physician’s office with a 2.0 cm laceration on his right index finger. After the physician sutured the finger, the patient asked the physician to evaluate the swelling of his left leg and ankle. An expanded, problem-focused history and performing a physical examination with low complexity medical decision-making. In this case, append modifier 25 with 99213.
References:
John Verhovshek; https://www.aapc.com/blog/44787-documenting-e-m-services-by-time/ ; November 29, 2018.
CPT 99213 https://www.codingahead.com/cpt-99213-outpatient-e-m-services-established-patient-20-29-minutes/
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