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The Noob-Friendly Guide to Medical Billing and Coding for Primary Care

Should you use 99213 or 99214 for your patient visit?

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. Many leave money on the table and “undercode” for fear of being flagged or audited by CMS or commercial payers. 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. However, when it comes to medical billing, payers might not be able to differentiate between innocent mistakes and deliberate missteps.

Medical billing and coding is not taught in medical school and is only briefly reviewed during residency training. With an emphasis on outpatient primary care, the basic review below is a good guide for new or in-training physicians and a great refresher for seasoned clinicians.

Here is everything you will learn in this guide:

  1. Different types of office visits
  2. Elements of medical documentation
  3. How to determine the level of complexity of a visit
  4. Complexity of medical decision-making
  5. Examples
  6. Other billable services

1. Different Types of Office Visits

When billing for an outpatient visit, you need to know whether you have a new or an established patient. 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.

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.

2. Elements of Medical Documentation

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.

Several components of your documentation are used to define the level of the visit or E/M service you provide. 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 99202 and 99203 if it is a new patient. See table 1.).

complexity
office visit new

office visit established
low9920299213
moderate9920399214
high9920499215
Table 1. Most commonly used E/M codes.

There are several elements of medical documentation, but the key components are history, exam and medical decision-making (Table 2). 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.  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.

Face-to-face time, for documentation purposes, is the actual time spent with the patient. However, most clinicians spend some time before the visit reviewing the chart and after the visit completing the visit note. 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.

Some clinicians could be tempted to  bill based on time for all their visits so they can bypass all the onerous medical documentation requirements. 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. 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. 

3. How to Determine Level of Complexity of a Visit

As mentioned earlier, three key components of your documentation determine the E/M service level for an outpatient visit: history, exam and medical decision-making.

Key Components
History
Exam
Medical Decision-Making
Table 2. Key components of medical documentation.

Determining the level of complexity is complex, but we will do our best to simplify it. Each of these key components hase a subset of elements that determine the extent of the history and examination as well as the complexity of the medical decision-making. 

Elements of Key Components
History
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical History (PMHx)
Past Surgical History (PSHx)
Family History (FHx)
Social History (SHx)
Exam
Number of body areas or organ systems examined
Medical Decision-Making (MDM)
Number of diagnoses considered
Number of management options considered
Amount of information obtained reviewed and analyzed
 (medical records, lab and imaging diagnostic tests)
Table 3. Elements of key components.

The extent of the history and exam can be problem-focused, expanded problem-focused, detailed or comprehensive, while the complexity of the medical decision-making can be straightforward, low-complexity, moderate complexity or high-complexity (Table 4).

HistoryExamMedical Decision Making
Problem-Focused (PF)Problem-FocusedStraightforward (SFW)
Expanded Problem-Focused (EPF)Expanded Problem-FocusedLow-Complexity (LCx)
Detailed (Det)DetailedModerate-Complexity (MCx)
Comprehensive (Comp)ComprehensiveHigh-Complexity (HCx)
Table 4. Type of history and exam. Complexity of medical decision making.

History

The type of history depends on the extent of elements obtained during the visit (CC, HPI, ROS, PMHx, PSHx, FHx, SHx). For example, a problem-focused or expanded problem-focused history would only include a single problem with these elements: CC, HPI, +/- ROS (i.e., a patient with a cold). A detailed history would include chief complaint, extended history of present illness, extended review of systes and pertinent past medical, family or social history. (See table 5.)

Type of HistoryCCHPIROSPFSH*
PFbrief
EPFbriefpertinent
Detailedextendedextendedpertinent
Comprehensiveextendedcompletecomplete
*PFSH = PMHx, PSHx, FHx, SHx
Table 5. Elements required for each type of history.

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. Per CMS documentation guidelines, an extended HPI should describe at least four elements of the present HPI or the status of at least three chronic conditions.

The elements of the HPI are the descriptors of a medical problem. Think of the old mnemonic OPQRST (onset, provocative factors, quality/quantity, radiation, severity, timing). For example, the following HPI has four elements and would qualify as an extended HPI.

Patient c/o diarrhea.
Symptoms present for two days.
Denies any blood in the stool.
No recent traveling.

Since you need to a complete review of systems (more than ten systems) to be able to meet the criteria for a comprehensive history, some clinicians, to get more “points” into the history component, type something like this: “All systems reviewed and negative except for pertinent positives in history of present illness.” or “10/14 review of systems completed and were negative except as stated above in HPI.” These kinds of statements are unnecessary. Is very rare for a clinician to review more than ten systems in a visit. Also, you only need to review two systems to bill a 99214 or 99203. A decent documentation of your HPI most likely will satisfy the requirements for a detailed history.

Most EHRs automatically include some past medical, family and social history into the note, typically in a section different from the HPI. However, it doesn’t matter if the ROS and past history are included in or outside  the HPI section.

Exam

 A comprehensive examination involves a general multi-system examination or complete examination of a single organ system. It is fairly easy to document a comprehensive exam using StatNote’s no-touch exam template, because everything can be gathered from entering the room, greeting the patient and shaking their hand. 

This template covers nine organ systems or elements required for a comprehensive exam. You could then revise the template or add pertinent findings to it.

General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Hearing grossly intact. No nasal discharge.
Neck: Neck is supple. No masses or thyromegaly.
Respiratory: Respirations are non-labored. No wheezing.
Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
CV: No lower extremity edema.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Without obvious focal neurological deficits. Sensation and motor functions grossly normal.

Medical Decision-Making

We now know that each of the three key components have specific elements that are taken into account to determine the type of history or exam and the complexity of the medical decision-making. Determining the complexity of your decision-making is the most important part of the process since it will ultimately dictate the level of the visit.

The CMS’s Patients Over Paperwork initiative streamlines regulations to reduce burden and increase efficiency. Effective January 1, 2021, practitioners will have the choice to document office/outpatient E/M visits via medical decision-making or time. In other words, if you feel frustrated about all the complexity it takes to determine the type history and exam, in 2021 you will need to focus only on the medical decision-making to determine the level of your visit.

A new patient must meet or exceed all of the three key components required to qualify for a particular level of E/M service, while an established patient must meet only two of the three. (I.e., you could bill for a 99215 for an established patient visit if you documented a complex exam and a high-complexity medical decision, even if your history is just problem-focused. However, to bill for a 99205 for a new patient, you will need all three key components: a complex history, a complex exam and a high-complexity medical decision.)

Table 6. Quick-reference guide to determine level of E/M code for an outpatient visit.

4. Complexity of Medical Decision-Making

Medical decision-making depends on three elements: 

  1. The number of diagnoses or management options.
  2. The amount and/or complexity of data to be reviewed (medical records, diagnostic tests).
  3. The risk of significant complications, morbidity and/or mortality associated with the patient’s problem(s). 

To reach a level of medical decision-making, two of the three elements must either be met or be exceeded according to the next table of progression.

MDM LevelNumber of DiagnosesData ReviewedRisk of Complications, M&M
StraightforwardMinimalMinimal or NoneMinimal
Low-ComplexityLimitedLimitedLow
Moderate-ComplexityMultipleModerateModerate
High-ComplexityExtensiveExtensiveHigh
Table 7. Medical decision-making progression of complexity according to diagnosis, data and risk elements.

Indicators of complexity

  • Undiagnosed problem > identified problem.
  • Number of diagnostic tests. +++ > +
  • Problems that are worsening or failing to change as expected > Problems that are improving or resolving.
  • Need for a consult from specialist > No need for consult.

That is why coding experts will tell you to document the MEAT for each diagnosis in your note. MEAT stands for the following: 

  • Monitor disease progression 
  • Evaluate test results or response to treatment
  • Assess or address ordering tests, discussion, counseling
  • Treatment documentation (medications, therapies).

Since only two out of three elements must be met to reach a MDM level of complexity, let’s focus on the number of diagnoses and risk. For data reviewed, just keep in mind documenting labs or imaging ordered and, if reviewed, comment on the findings (for example, “WBC elevated” or “CXR unremarkable”). Document when medical records were requested and note when history was obtained from sources other than the patient (for example, family, caretaker or other medical records). Also document the relevant information obtained.

The level of risk of complications, morbidity and mortality can be minimal, low, moderate or high. This is based on the risks associated with these categories:

  • Presenting problem(s)
  • Diagnostic procedure(s)
  • Possible management options.

Let’s go through a few examples pertinent to primary care. You can find a more comprehensive table of risks here: CMS documentation guideline (page 18). 

Minimal risk

A patient with a self-limited or minor problem.

  • A mosquito bite.
  • Patient with a cold managed with rest and gargles.

Low risk

Acute uncomplicated illness or injury needing over-the-counter drugs.

  • Ankle sprain treated with ibuprofen.
  • Allergic rhinitis treated with nasal fluticasone spray.

One stable chronic illness.

  • Well-controlled diabetes or hypertension.

Two or more self-limited or minor problems.

Moderate-risk

One or more chronic illnesses with mild exacerbation, progression or side effects to treatment.

  • Uncontrolled diabetes.
  • Patient with hypertension who develops side effects to Amlodipine.

Two or more stable chronic illnesses.

  • Visit for diabetes and hypertension.

Acute uncomplicated illness needing prescription drug management.

  • UTI treated with antibiotics.
  • Dermatitis needing a prescription for topical triamcinolone.

High-risk

One or more chronic illnesses with severe exacerbation.

An acute or chronic illness that poses a threat to life or bodily function (possibly any patient you see in your office that needs to go to the ED).

  • Diabetes with severe hyperglycemia or DKA.
  • Patient with neurologic symptoms, needing to r/o stroke.
  • Patient with chest pain suspecting MI.
  • Patient with RLQ abdominal pain and fever, suspecting appendicitis. 

The AAFP offers this reference card that assigns a point system to each key component-specific element of the medical documentation to ensure that the documentation meets criteria for a 99214 visit. It also details the differences in documentation requirements for level 4 visits with new and established patients.

5. Examples

Now that we understand all the elements that go into determining the appropriate billing code let’s review a few examples of the most common E/M codes. You can go back to table 6 to review the required key components.

Remember that new patient visits require three out of three key components (history, exam, MDM) and established patients only require two out of three. To oversimplify the concept, you could think that a 99213 would be equivalent to a 99202, 99214 equivalent to a 99203, and a 99215 equivalent to a 99204. (See figure 1.)

Figure 1. Simplifying the comparison between new vs. established E/M codes.

Progress note 1 – URI

CC: Pt c/o cold symptoms.

HPI
Presents with rhinorrhea, nasal congestion, headache, sore throat, cough, non-productive.
Symptoms present for days.
No SOB/wheezing.
No fever.
No sick contacts.

PE
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Tympanic membranes are clear, No sinus tenderness, Mild pharyngeal erythema, no exudates, Nasal mucosa erythematous and edematous. Clear rhinorrhea.
Neck: Neck is supple. Tender anterior lymphadenopathy.
Respiratory: Respirations are non-labored. Lungs are clear to auscultation. No wheezing.
Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
CV: Normal rate, Regular rhythm, No murmur.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN II-XII grossly normal.

A/P
# URI
Likely viral.
Reassurance. Supportive care.
Increase fluid intake, rest.
Fever control with Tylenol/Ibuprofen. 
OTC decongestant. pseudoephedrine, Benadryl.
Salt water gargles, ice chips to soothe throat tid. Lozenges.
Increase humidity using a humidifier by bedside. Exposure to steam for expectoration.
Nasal saline prn.
Return to clinic if not improved over the next several days, or if getting worse.

MDM is low: an acute illness treated with over-the-counter drugs. The exam is detailed (even though only an EPF exam is required). The HPI is EPF.

If this was an established patient, it would meet criteria for a 99213 visit. (Check table 6). If this was a new patient, it would qualify only for a 99202 visit. 

99213 – Established patient: Low complexity MDM. EPF history or EPF exam. (only two out of three key components required).

99202 – New patient: Straightforward MDM. EPF history and EPF exam. (Three out of three key components required).

It could qualify for a 99203 if you had a detailed HPI, which would require a full past medical, social and family history (which most likely you don’t have since it’s a new patient) and a complete ROS. 

For the sake of argument, let’s say that this is a new patient only because it is new to your department but another doctor in your multi-specialty group has already documented the patient’s medical, social and family history. Assuming that your EHR automatically added all the past medical history to the note (PMHx, FHX, SHx, etc), you would still need to review ten organ systems. In this patient with a common cold, a review of two organ systems would be sufficient (constitutional and respiratory). You could add a complete review of systems to meet criteria for a detailed HPI; however, that would probably be a stretch.

Progress note 2 – DM/HTN/HLD

CC: Here for DM, HTN, HLD f/u

HPI
Diabetes type 2
On metformin.
Compliant with medications. On ACEI. No hypoglycemic events. 
Not checking blood glucose at home.
Not complaints of foot pain or paresthesias.
Seen by ophthalmologist <1 yr ago.
Following a low carb diet. Exercising.

Hypertension
On lisinopril. 
Compliant with medications. 
Does not report any headaches, blurry vision, dizziness, chest pain, shortness of breath, or palpitations.
Following a low salt diet. Exercising.

Hyperlipidemia
Compliant with statin. No side effects.
Following a low-cholesterol diet.

PE
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Hearing grossly intact. No nasal discharge.
Neck: Neck is supple. No masses or thyromegaly.
Respiratory: Respirations are non-labored. No wheezing.
Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
CV: No lower extremity edema.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN II-XII grossly normal.

A/P
# Diabetes Mellitus type 2
Controlled. 
Continue current management. 
Patient is on aspirin, ACEI, statin.
Lipid panel checked less than a year ago.
Microalbumin checked less than a year ago. 
Continue/Increase dietary efforts and physical activity.
Routine diabetic retinopathy screening: up-to-date.
 
# HTN
Controlled.
Continue current medications. No change in management.
Discussed DASH diet and dietary sodium restrictions. 
Continue/Increase dietary efforts and physical activity. 

# Hyperlipidemia
Stable. Continue with current management without changes.
Discussed healthy diet and lifestyle.

MDM is moderate complexity: three stable chronic illnesses. The exam is comprehensive. The history is detailed.

99214 – Established patient: Moderate complexity MDM. Detailed history or detailed exam. (only two out of three key components required).

99203 – New patient: Low complexity MDM. Detailed history and detailed exam. (Three out of three key components required).

Even though we have a moderate-complexity MDM in this patient with three chronic problems and we have a detailed history, we cannot bill for a 99204 because we don’t have a comprehensive history.

Progress note 3 – uncontrolled hypertension

CC: Pt c/o high BP.

HPI
Hypertension
On lisinopril. 
Not compliant with medications. 
Endorses headaches.
Does not report any blurry vision, dizziness, chest pain, shortness of breath, or palpitations.
Not following a low salt diet. Not exercising.

PE
VS: 160/90, 80, 26, 98.3
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Hearing grossly intact. No nasal discharge.
Neck: Neck is supple. No masses or thyromegaly.
Respiratory: Respirations are non-labored. No wheezing.
Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
CV: No lower extremity edema.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN II-XII grossly normal.

# HTN
Not Controlled.
Continue lisinopril, add HCTZ. 
Discussed DASH diet and dietary sodium restrictions. 
Continue/Increase dietary efforts and physical activity.

MDM is moderate given the moderate risk of complications. In this case, the patient has a chronic condition with mild progression or exacerbation. If it was an hypertension emergency, the MDM complexity would be high given the high risk of complications, morbidity and mortality.

This note would qualify for a 99214 or 99203, depending whether it is an established or new patient.

Progress note 4 – chest pain

CC: chest pain.

HPI
Pt c/o chest pain that started this morning.
Pain located on left side.
+ radiation to left arm.
Described as pressure.
Lasts for a few minutes.
On exertion.
+ SOB. No palpitations.
No emotional stressors.

PE
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Hearing grossly intact. No nasal discharge.
Neck: Neck is supple. No masses or thyromegaly.
Respiratory: Respirations are non-labored. No wheezing.
Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
CV: No lower extremity edema.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN II-XII grossly normal.

A/P
# Chest pain
EKG revealing possible ST elevation MI.
Gave aspirin to patient. Will send to ED.

MDM is high complexity: an acute illness that may pose a threat to life or bodily function. This patient may be having an MI.

In this and all the previous notes, we used a comprehensive exam. As previously mentioned, you can ensure that you have a comprehensive exam by using a template that you then edit according to your findings. This way you can focus on two key components of your documentation: history and MDM. 

99215 – Established patient: High-complexity MDM. Comprehensive history and comprehensive exam.

99204 – New patient: Moderate-complexity MDM. Comprehensive history and comprehensive exam.

If this was an established patient, even though we don’t have a comprehensive history, we do have a comprehensive exam and high-complexity MDM (2/3).

If this was a new patient, it wouldn’t meet criteria for a 99204 or 99205 visit because you wouldn’t have a comprehensive history. This would require an extensive HPI, a complete ROS and complete past medical history. However, if you spent 45 minutes or more with the patient you could bill based on time as long as you document something along these lines:

Total encounter time was 45 minutes with more than 50 percent of the visit involved in counseling/coordination of care. An EKG revealed ischemic changes and an ambulance was called, EMS took the patient to the ED and I personally discussed the case with the ED physician.

6. Other billable services

Other services you can bill for include the following:

  • Preventive medicine services
  • Counseling services
  • Nursing home visits
  • Home visits
  • Telephone services
  • Telehealth visits
  • Online medical evaluation
  • Work-related or medical disability exams
  • Care plan oversight
  • Cognitive assessments
  • Chronic care management services
  • Transitional care management services
  • Advance care planning
  • Procedures

Don’t limit yourself to billing only for 99213s and 99214s. In our next article, we will explore all your options. Chances are that you are already providing some of these services, but you might not be documenting or billing for it.

You can also find more dot phrases and commonly used CPT codes in our book. Get it today for free on Amazon using kindleunlimited.

Final Thoughts

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What other billing and coding tips do you use? Feel free to share. Comment below.

Posted on: September 9, 2020, by :

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