Established Patient CPT code and description
- 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
- 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter
Established patient Office Visits (CPT Codes 99211-99215)
Today’s topic for discussion is the family of CPT codes for Evaluation and Management, “Office Visits Established” — 99211, 99212, 99213, 99214,and 99215. These codes are used for Office or Other Outpatient Visits for the Established patient.
If a claim with these codes is reviewed the medical documentation for each code should include the following information:
For code 99211, the office or outpatient visit for the evaluation and management of an established patient may not require the presence of a physician or other qualified health care professional.
Here’s a tip for billing code 99211: the presenting problem or problems should be minimal. Typically, five minutes are spent performing or supervising services such as blood pressure checks.
For code 99212, the office or other outpatient visit is for the evaluation and management of an established patient, and requires at least two of these three key components be present in the medical record:
- A problem focused history
- A problem focused examination;
- Straightforward medical decision making
A tip for billing 99212 is that the presenting problems are usually self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
For code 99213, the expanded assessment for office or other outpatient visit requires at least two out of these three key components to be present in the medical record:
- An expanded problem focused history
- An expanded problem focused examination
- Medical decision making of low complexity
A tip for code 99213 is to think of expanded visits as a sum of the continued symptoms or another extended form of the problem. Usually, the presenting problem or problems are of low to moderate severity. Typically 15 minutes are spent face-to-face with patient and/or family.
Evaluation and Management (E/M) Services Guidelines
Guidelines Common to All E/M Services
Time
The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions of the CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 was done to assist in selecting the most appropriate level of E/M services. Beginning with CPT 2021, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). Different categories of services use time differently. It is important to review the instructions for each category.
Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult to provide accurate estimates of the time spent face-to-face with the patient.
Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service. Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.
When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of services. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional. For office or other
outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.
A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).
When prolonged time occurs, the appropriate prolonged services code may be reported. The appropriate time should be documented in the medical record when it is used as the basis for code selection.
- Total time on the date of the encounter (office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).
If you look through your Current Procedural Terminology (CPT®) book, you will notice that many of the evaluation and management (E/M) code descriptors include typical times. These typical times are averages of how long it takes a physician to complete all components of a visit at that level. As is true with averages, some times are going to be higher and some will be lower, depending on the actual clinical circumstances. Therefore, in most cases, time is only a “contributory factor” in determining which level of evaluation and management (E/M) to report for a visit. Usually, a level of E/M service is determined by the “key components” of history, examination, and medical decision making. However, if you end up spending greater than fifty percent of the total visit counseling/coordinating care, you can use time as the key factor in determining the level of E/M service that you report. Typical times are listed below for new and established office or other outpatient E/M services:
Established Patient Visit Typical Time (minutes)
99212 10
99213 15
Here’s an example:
You see a 20-month old child with an injured leg and complete two out of the three key components (expanded problem focused history, expanded problem focused exam, or medical decision making of low complexity) necessary to code a 99213. Upon review of the chart, you notice that the child is due for a refill on his asthma medication. You ask the mom how it has been going with the current medications and the mom starts talking about recent issues with getting the child to cooperate taking his medications. The physician spends a great deal of time counseling the mom on ways to administer the medications and how to be sure the child is getting enough. The physician also discusses the important of taking peak flow meter ratings.
If you look in your CPT book, you will note that 99213 lists a typical time of 15 minutes, while a 99214 has a typical time of 25 minutes.
In order to determine whether you can code for time as the key factor, you need to answer the following questions:
A) How much time did I spend either counseling or coordinating care for the patient?
B) How much time did I spend in total for the whole visit (including time spent providing key components and time spent counseling and/or coordinating care)?
C) What percentage of B is A?
If the answer to C is equal to or less than fifty percent, then the key components should be used to determine the level of code to report. If the answer to C is greater than fifty percent, then you can use time as the key factor in determining which level of service to report; the level of key components is no longer a factor for determining the level of code to report. From our example above:
If the answer to B is 30 minutes and the answer to A is 16 minutes, then the answer to C is 53% and you could then report a 99214 (typical time for 99214 listed in CPT is 25 minutes).
To drive home the point, here are some variations with different results:
If the answer to B is 40 minutes and the answer to A is 22 minutes, then the answer to C would be 55% and you could then report a 99215 (typical time for 99215 listed in CPT is 40 minutes).
If the answer to B is 42 minutes and the answer to A is 19 minutes, then the answer to C would be 45% and you would then report a level of service based on key components (in our example above, you would report 99213).
Established Patient E/M
CPT MDM 2020 Typical Time 2021 Range
99212 Straightforward 10 min 10-19 min
99213 Low complexity 15 min 20-29 min
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