CPT 99213 is defined as: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:
• An expanded problem focused history; • An expanded problem focused examination; • Medical decision making of low complexity usually, or straight forward as the presenting problem(s) are of low to moderate severity.
A physician will be left with the options of billing E/M for either code 99211 thru 99215 for an established patient. Usually, the correct level of CPT code (ignoring coding by time) can often be narrowed down to two or three choices by a proper evaluation of the patient and documenting the office visit correctly. The usual choices that remain for the physician at the end are 99212, 99213, 99214.
There might be times when the physician wants to put a code down without really understanding the complexities of the coding system and that will end up leaving money on the table which we are trying to avoid.
For example:
If an established patient presents for a second follow-up of a single complaint such as chronic cough and it is decided that it is stable or improving, a CPT 99212 may be warranted.
However, in the evaluation of the patient, if the provider takes an expanded history and the physical exam is re-evaluated to include performance and documentation of at least six bulleted elements from one or more organ systems or body areas. Then it will qualify as an expanded problem focused exam. That being said, if your History and Physical Exam meet criteria, then the Medical Decision Making is not needed in the calculation of the level and you may capture your 99213.
Remember, in an established patient, you need only meet two out of three criteria; History, Physical Exam and Medical Decision Making to qualify.
That being said, we certainly will be making a medical decision, but according to the 1997 guidelines (which I prefer to use for a variety of reasons) we capture our 99213 as long as the medical necessity is apparent.
In another example, If the same patient has a single straightforward new complaint to discuss with the examiner, during the follow up for the chronic cough, such as an orthopedic complaint that is worsening, a CPT 99213 and even a CPT 99214 depending upon the complete exam fulfilling two out of the three main components (that being History Physical Exam and Medical Decision Making (MDM) may be appropriate. Of course, medical necessity is required to substantiate the level of service billed.
As a physician, if you consider billing by time then a 99213 requires an average of visit of 15 minutes in which at least 7.5 minutes or 50% of your time was spent in counseling or coordinating care.
Remember, CPT 99213 requires documentation of at least one system when you compare it with CPT code 99212 and an expanded problem focused (EPF) history is required as well for a 99213.
The revenue captured from properly documenting a 99213 over a 99212 can add up to thousands of dollars annually. You want to make sure you are properly documenting your medical records and capturing the revenue you deserve based on the work you are performing. You do the work, get paid for what you do.
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