CPT® 99212-99215; Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient - JF Part B
CPT® 99212-99215; Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient
In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.
This is to update providers of the claim review findings for CPT® 99212-99215; Office or other outpatient visit for the evaluation and management of an established patient. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.
The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 99212-99215; Office or other outpatient visit for the evaluation and management of an established patient The quarterly edit effectiveness results from January 1, 2024, too March 31, 2024, are as follows:
Top Denial Reasons
- Failure to return records
- The documentation submitted supported the key elements and/or reasonable necessity of a lower level of service.
- The documentation submitted did not include a valid signature and/or credentials.
Educational Resources
Education
Providers report these codes for established patients being seen in the doctor's office, a multispecialty group clinic, or other outpatient environment. All require a medically appropriate history and/or examination that describes an encounter that may not require the presence of a physician or other qualified health care professional. For the remainder of codes within this range, code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management.
- 99212 for a visit that entails straightforward MDM. If time is used for code selection, a total time of 10 minutes must be met or exceeded on the day of the encounter.
- 99213 for a visit requiring a low level of MDM or meeting or exceeding 20 minutes of total time;
- 99214 for a moderate level of MDM or meeting or exceeding 30 minutes of total time; and
- 99215 for a high level of MDM or meeting or exceeding 40 minutes of total time.
These codes are used to report office or other outpatient services for an established patient. A medically appropriate history and physical examination, as determined by the treating provider, should be documented. The level of history and physical examination are not considered when determining the level of service. Codes should be selected based upon the current CPT Medical Decision Making table. Alternatively, time alone may be used to select the appropriate level of service. Total time for reporting these services includes face-to-face and non-face-to-face time personally spent by the physician or other qualified health care professional on the date of the encounter. Telemedicine services may be reported by the performing provider by adding modifier 95 to the procedure code and/or using the appropriate place of service (POS) indicator; POS 02 for telehealth when the originating site is not the patient’s home and POS 10 for telehealth services when the originating site is the patient’s home.
In August 2023, CMS updated the MLN Booklet Evaluation and Management Services Guide. The 21-page guide is available on the CMS Evaluation and Management webpage. The changes included in the booklet are indicated in red font.
