Billing Codes

Physicians have very little control any more over the format to be used to charge for services. In order to satisfy our patients’ insurance companies, government agencies, and other third party payers, we are virtually forced to use a complex, cumbersome system based on Current Procedural Terminology (CPT) codes. While the technicalities of the system are overwhelming, some generalizations can be made. Each and every "procedure", regardless how small or large, must be billed for, and must be billed for separately. Physician's services are coded on the complexity (not time) of the care each and every patient (not family) receives (whether at a visit or over the phone, etc.).

The following simplified guide describes the national criteria for the most frequently used categories of visits for established patients (different codes are required for “new” patients or patients who have not been seen in three years):

  • 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal.
     
  • 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: (1) a problem focused history (chief complaint; brief history of present illness or problem); (2) a problem focused examination (an examination that is limited to the one affected body area or organ system); and (3) straightforward medical decision making. Usually, the presenting problem(s) are self-limited or minor.
     
  • 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: (1) an expanded problem focused history (chief complaint; brief history of present illness; problem pertinent system review); (2) a problem focused examination (an examination of the affected body area or organ system and other symptomatic or related organ systems); (3) medical decision making of low complexity. Usually, the problem(s) are of low to moderate severity.
     
  • 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: (1) a detailed history (complaint; extended history of present illness, extended system review, pertinent past, family and/or social history); (2) a detailed examination (an extended examination of the affected body area(s) and other symptomatic or related organ system(s)); (3) medical decision making of moderate complexity. Usually, the presenting problem(s) are of moderate to high severity.
     
  • 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: (1) a comprehensive history (chief complaint, extended history of present illness; complete system review; complete past, family and social history); (2) a comprehensive examination (a complete single system specialty examination or a complete multi-system examination); (3) medical decision making of high complexity. Usually, the presenting problem(s) are of moderate to high severity.

Note: In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor-unit time in the hospital or nursing facility), then time is considered the key or controlling factor to qualify for a particular level of services (5, 10, 15, 25 or 40 minutes).

Codes used for physical exams at various ages:

Established Patient Patient Age New Patient
99391 < 1 99381
99392 1 - 4 99382
99393 5 - 11 99383
99394 12 - 17 99384
99395 18+ 99385

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