Cpt 99213 - learning the Basics of E & M Coding Guidelines

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Cpt 99213 is defined as: Office or other patient visit for the estimation and supervision of an established patient, which requires at least two of these three key components:

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• An vast problem focused history;
• An vast problem focused examination;
• curative decision development of low complexity usually, or right transmit as the presenting problem(s) are of low to moderate severity.

A physician will be left with the options of billing E/M for whether code 99211 thru 99215 for an established patient. Usually, the precise level of Cpt code (ignoring coding by time) can often be narrowed down to two or three choices by a proper estimation 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 assuredly insight 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 particular complaint such as persisting cough and it is decided that it is carport or improving, a Cpt 99212 may be warranted.

However, in the estimation of the patient, if the provider takes an vast history and the bodily exam is re-evaluated to consist of doing and documentation of at least six bulleted elements from one or more organ systems or body areas. Then it will qualify as an vast problem focused exam. That being said, if your History and bodily Exam meet criteria, then the curative Decision development 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, bodily Exam and curative Decision development to qualify.

That being said, we assuredly will be development a curative decision, but according to the 1997 guidelines (which I prefer to use for a range of reasons) we capture our 99213 as long as the curative necessity is apparent.

In another example, If the same patient has a particular simple new complaint to discuss with the examiner, during the consequent up for the persisting 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 bodily Exam and curative Decision development (Mdm) may be appropriate. Of course, curative necessity is required to substantiate the level of service billed.

As a physician, if you reconsider 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 assess it with Cpt code 99212 and an vast problem focused (Epf) history is required as well for a 99213.

The income 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 curative records and capturing the income you deserve based on the work you are performing. You do the work, get paid for what you do.

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