What are the rules for CPT code 99213?
Asked by: Flavio Ullrich | Last update: February 23, 2025Score: 5/5 (46 votes)
What are the criteria for 99213 billing?
CPT code 99213 is an evaluation and management (E/M) code for office or other outpatient visits, typically used for established patients who require a low level of medical decision-making (MDM) and management. If choosing the code based on time, the encounter involves 20 or more minutes of total time on the visit date.
What are the documentation guidelines for 99213?
- Relevant documentation: To support the 99213 code, include pertinent information such as the reason for the visit, history of present illness, review of systems, physical examination, assessment, and plan of care.
What are the rules for billing new patient visits?
Three-year rule: The general rule to determine if a patient is new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service. Some payers may have different guidelines, such as using the month of their previous visit, instead of the day.
What is the golden rule in medical billing?
The golden rule of healthcare billing and coding departments is, “Do not code it or bill for it if it's not documented in the medical record.” Providers use clinical documentation to justify reimbursements to payers when a conflict with a claim arises.
What is a level 3 or 2 office / outpatient visit in medical coding? 99213 & 99203 explained
Is 99213 a preventive code?
However, if you bill an additional office visit code (for example, 15 minute expanded problem visit code 99213 with modifier 25), this is NOT considered a preventive service, and may be subject to deductibles, copays or coinsurance.
What is the difference between a 99213 and a 99214 visit?
This code is applied when a patient's care involves moderate complexity, such as managing multiple medical conditions or addressing more serious symptoms. The reimbursement rate for this CPT code is higher than 99213 because it includes face-to-face time spent between patient and physician.
How long is a new patient office visit?
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
What is an example of a 99213 visit?
An example of a 99203 or 99213 is a sinus infection treated with an antibiotic. Although the prescription makes the risk component moderate, the one acute uncomplicated illness is a low-complexity problem, and there are no data points.
Can 99213 be billed for telehealth?
These services should be billed using standard E/M codes. For example, a level 3 office visit provided to an established patient via telehealth should be billed using code 99213.
Which of the following cannot be counted for time-based E&M coding?
The only time that can be included in the calculation of total time is the time personally spent by the physician or QHP on the date of the encounter. Again, ancillary staff time cannot be counted; this includes medical assistants, patient care technicians, licensed vocational nurses, licensed practical nurses, etc.
How to code a 99213?
- Provide an Expanded Problem-Focused History. ...
- Thoroughly Document the Expanded Problem-Focused Examination. ...
- Detail the Medical Decision Making of Low Complexity. ...
- Document Face-to-Face Time and Direct Interaction. ...
- Use Specific and Descriptive Language.
What is the procedure code for follow up visit?
Follow-up visits, like initial visits, should be coded using the appropriate evaluation and management (E/M) code (i.e., 99211–99215).
When should 99213 be billed?
CPT® code 99213: Established patient office or other outpatient visit, 20-29 minutes.
What is a complex office visit?
Complex visits are defined as those with over two diagnoses (the mean of diagnoses made per visit) and/or those with over three prescription medications (the mean of medications prescribed per visit).
Does CPT 99213 need a modifier?
If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with psychological testing (such as CPT code 96101), modifier 59 would be appended to the testing code.
Is CPT code 99213 covered by Medicare?
Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213, furnished during a single beneficiary encounter.
Can you bill an office visit with a preventive visit?
Physicians are not prohibited from coding and billing for both preventive and problem-focused E/M services when they are performed during the same appointment.
What is the midpoint rule in CPT?
CPT® has long had a unit of time rule that a unit of time is met when the midpoint has passed. That is, you've reached an hour after 31 minutes. There are many CPT® codes that follow this mid-point time rule including critical care, psychotherapy, and physical and occupational therapy services that are time based.
What is the rule of 7 billing?
If eight or more minutes are left over, you can bill for an additional unit. But if seven or fewer minutes remain, Medicare will not reimburse you for another full unit, and you must essentially drop the remainder.
What is an allowable in medical billing?
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan's allowed amount, you may have to pay the difference. (
What is Platinum rule?
You've probably heard of the golden rule: treat others how you'd like to be treated. But to build stronger relationships (workplace or otherwise), we must use this knowledge to apply the platinum rule: treat others as they would like to be treated!