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

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

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• An expanded question focused history;
• An expanded question focused examination;
• medical decision production 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 strict level of Cpt code (ignoring coding by time) can often be narrowed down to two or three choices by a proper appraisal of the inpatient 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 literally understanding the complexities of the coding law and that will end up leaving money on the table which we are trying to avoid.

For example:

If an established inpatient presents for a second follow-up of a singular complaint such as lasting cough and it is decided that it is carport or improving, a Cpt 99212 may be warranted.

However, in the appraisal of the patient, if the victualer takes an expanded history and the physical exam is re-evaluated to contain doing and documentation of at least six bulleted elements from one or more organ systems or body areas. Then it will qualify as an expanded question focused exam. That being said, if your History and physical Exam meet criteria, then the medical Decision production 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 production to qualify.

That being said, we literally will be production a medical decision, but agreeing 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 someone else example, If the same inpatient has a singular straightforward new complaint to discuss with the examiner, while the succeed up for the lasting cough, such as an orthopedic complaint that is worsening, a Cpt 99213 and even a Cpt 99214 depending upon the unblemished exam fulfilling two out of the three main components (that being History physical Exam and medical Decision production (Mdm) may be appropriate. Of course, medical necessity is required to substantiate the level of service billed.

As a physician, if you think 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 law when you collate it with Cpt code 99212 and an expanded question focused (Epf) history is required as well for a 99213.

The wage 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 wage you deserve based on the work you are performing. You do the work, get paid for what you do.

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