This 99213 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99211-99215. CPT® 99213 represents the middle (level 3) office or other outpatient established office patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). This procedure code lecture for established office patient visits is part of a complete series of CPT® lectures written by myself. I am a board certified internal medicine physician with over ten years of clinical hospitalist experience in a community hospitalist program providing physician services for a large regional hospital system. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and other non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex and archaic world of hospital and clinic based coding requirements.
These original lectures and accompanying resources are used by myself to stay compliant with the rules and regulations of the Centers for Medicare & Medicaid Services (CMS). All my CPT® lectures (including CPT® 99214 and CPT® 99215) have been organized in one easy-to-find resource on Pinterest and can be accessed by clicking this link. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these CPT® E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.
This medical billing code can be billed based on time when certain requirements are met. Documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99213 documentation should be supported by the 1995 or 1997 E/M guidelines referenced above. The three important coding components for an established outpatient clinic note are the:
As you know, documenting the status of three chronic medical conditions can substitute for the HPI. Add in one problem pertinent review of system and this is the minimum history documentation required for CPT® 99213. With at least 6 bullets documented in the physical exam, this note is complete and accurate and meets documentation requirements to get paid for a 99213. Here is another clinical progress note example of appropriate documentation for a CPT® 99213:
What is the distribution of CPT® code 99213 relative to other levels of service in this medical code group? The graph below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services. You can find these charts and graphs starting on page 9 of the link provided here. As you can see, between 2001 and 2010, the distribution of established patient office visits has shifted higher. The proportion of level four 99214 and level five 99215 reimbursements has increased by 15% and 2% respectively, while the proportion of level three 99213 services billed for payment has decreased by 8% between 2001 and 2010. On an absolute percentage basis, in 2010, CPT® code 99213 was being billed 46% of the time, down from 53% of the time ten years previously.
How much money does a CPT® 99213 pay? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99213 is worth 1.44 total RVUs for facility services and 2.05 total RVUs for non-facility. The work RVU for 99213 is valued at 0.97. A complete list of RVU values on common hospitalist E/M codes is provided at the attached URL. What is the Medicare reimbursement for CPT® code 99213? In my state, a CPT® 99213 pays about $48 (facility) and $68 (non-facility) in 2016. The dollar conversion factor for one RVU in 2016 is $35.8043.
My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.
These original lectures and accompanying resources are used by myself to stay compliant with the rules and regulations of the Centers for Medicare & Medicaid Services (CMS). All my CPT® lectures (including CPT® 99214 and CPT® 99215) have been organized in one easy-to-find resource on Pinterest and can be accessed by clicking this link. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these CPT® E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
99213 MEDICAL CODE DESCRIPTION
My interpretations detailed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access to Amazon through the 2015 CPT® standard edition pictured below and to the right. CPT® 99213 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient established patient services. The American Medical Association (AMA) describes the 99213 CPT® procedure code as follows:
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.
An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.
This medical billing code can be billed based on time when certain requirements are met. Documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99213 documentation should be supported by the 1995 or 1997 E/M guidelines referenced above. The three important coding components for an established outpatient clinic note are the:
- History
- Physical Exam
- Medical Decision Making Complexity
- Expanded problem focused history: Requires only 1-3 components for the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions. No past medical history or social history or family history is needed. Only 1 problem pertinent review of systems (ROS), that inquires about the system related to the problem identified in the HPI, is required.
- Expanded problem focused examination: 1997 guidelines require documentation of at least six elements identified by a bullet in one or more organ systems(s) or body area(s). 1995 guidelines require a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). The CMS E&M guide on pages 31 and 32 describes the acceptable body areas and organ systems on physical exam.
- Medical decision making of low complexity (MDM): This is split into three components. The 2 out of 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool?
- Diagnosis (2 points)
- Data (2 points)
- Risk (low); The risk table can be found on page 37.
CLINICAL EXAMPLES OF 99213
What are some progress note documentation examples for a CPT® 99213, the level 3 established patient visit in an office or other outpatient setting? Most doctors use the subject, objective, assessment and plan (SOAP) note format. A 99213 note could look like this:
S) No more abdominal pain (1 HPI). Mild Nausea (1 problem pertinent ROS)O) 120/80 80 Tmax 98.9 (three vital signs = one bullet) abdomen no masses; lungs clear; heart no murmur; legs no edema; skin no rash. (at least 6 total bullets)A) Nothing neededP) Nothing needed
In this example history (subjective) and physical (objective) meet the requirements to get paid for a 99213. Remember, the highest 2 out of 3 components determine the highest level of service for established patients in the clinic or other outpatient setting. Do note that linking an ICD code to a CPT® medical code is required for all visits submitted to CMS for reimbursement. Therefore, most progress notes should provide at least one ICD code to clearly indicate a purpose for the visit. I suspect this is necessary to meet the reasonable and necessary threshold, unless that can be inferred from other chart documentation. Medicare doesn't want to pay for doctors to talk about politics with their patients. There must always be an approved ICD code linked with the CPT® medical code when billed to CMS and most other insurance companies.
I think it's always a good habit to include at least on ICD code in your note documentation, even though it's not technically required for established patient clinic follow-up visits that can achieve compliance with history and physical elements alone. Remember, the highest supported level of documentation for 2 out of 3 from history, physical and medical decision making on established clinic patients determines the overall level of CPT® code service. For history, just one component of the HPI (character, onset, location, duration, what makes it better or worse etc...) or documentation of the status of three chronic medical conditions PLUS one problem pertinent review of system is required for this level three progress note. For physical exam, using 1997 E/M guidelines, documentation of six bullets from at least one organ system or body area is required. Remember, documentation of three vital signs can count as one bullet element. Here is another clinical example of a SOAP note for a CPT® 99213 established patient clinic visit:
I think it's always a good habit to include at least on ICD code in your note documentation, even though it's not technically required for established patient clinic follow-up visits that can achieve compliance with history and physical elements alone. Remember, the highest supported level of documentation for 2 out of 3 from history, physical and medical decision making on established clinic patients determines the overall level of CPT® code service. For history, just one component of the HPI (character, onset, location, duration, what makes it better or worse etc...) or documentation of the status of three chronic medical conditions PLUS one problem pertinent review of system is required for this level three progress note. For physical exam, using 1997 E/M guidelines, documentation of six bullets from at least one organ system or body area is required. Remember, documentation of three vital signs can count as one bullet element. Here is another clinical example of a SOAP note for a CPT® 99213 established patient clinic visit:
S)No SOB (1 problem pertinent ROS)O) 120/80 80 Tmax 98.9 (three vital signs = one bullet) abdomen no masses; lungs clear; heart no murmur; legs no edema; skin no rash. (at least 6 total bullets)A)HTN-stable, no changes planned.DM-stable, no changes planned.COPD-stable, no changes planned. (the status of three chronic medical conditions in place of HPI)P) Nothing
S) Nothing neededO) 120/80 80 Tmax 98.9 (three vital signs = one bullet) abdomen no masses; lungs clear; heart no murmur; legs no edema; skin no rash. (at least 6 total bullets)A) 1) HTN, controlled 2) DM II, controlled (two points for diagnosis)P) Nothing needed
According to the guidelines E/M risk table guidelines linked above, documenting the status of one chronic medical condition qualifies as low level risk in the medical decision making process. I have documented the status of two chronic medical conditions and that meets the criteria for diagnosis (2 points) and risk (low) for CPT® 99213 in MDM. This qualifies for low risk in the risk table based on their qualifying description as "one stable chronic illness, eg, well controlled hypertension, non-insulin dependent diabetes, cataract, BPH". I have meet my 99213 note requirements for 2 out of 3 areas by meeting minimum criteria for physical exam (6 bullets) and the decision making component (by documenting the status of two chronic medical conditions). Remember, reasonable and necessary is always part of any evaluation, as is the requirement for the visit to be face-to-face in nature.
The complicated table of risk, one of the elements used to determine overall complexity in medical decision making, can be reviewed once again on page 37. What I have on my quick reference E/M card below only represents examples of moderate and high risk elements due to space limitations. At least for the hospitalist population (as a consultant on observation status scenarios), most established outpatient coding decisions will not be determined based on low risk medical decision complexity. I rarely use low risk in the table for any progress note because I'm just not smart enough to memorize it. I generally only use the table of risk when determining moderate and high risk encounters. In addition, most of my patients in the hospital present with moderate or high risk complexity. However, I have linked to it on page 37 above for your quick reference should you desire a more detailed understanding. Here is another clinical example that meets minimum documentation requirements for a CPT® 99213:
The complicated table of risk, one of the elements used to determine overall complexity in medical decision making, can be reviewed once again on page 37. What I have on my quick reference E/M card below only represents examples of moderate and high risk elements due to space limitations. At least for the hospitalist population (as a consultant on observation status scenarios), most established outpatient coding decisions will not be determined based on low risk medical decision complexity. I rarely use low risk in the table for any progress note because I'm just not smart enough to memorize it. I generally only use the table of risk when determining moderate and high risk encounters. In addition, most of my patients in the hospital present with moderate or high risk complexity. However, I have linked to it on page 37 above for your quick reference should you desire a more detailed understanding. Here is another clinical example that meets minimum documentation requirements for a CPT® 99213:
S) HA present (one HPI). No nausea (1 problem pertinent ROS)O) NothingA) Chronic HA, stable. (one stable chronic illness is low risk)P) I discussed HA history with Neurologist Dr Smith today and I plan to get their formal opinion. (two points under data for discussing case with another healthcare provider)
That's all you need folks. Documentation of 2 out of 3 areas at their defined minimum requirements. That means one HPI (HA present), one problem pertinent ROS (no nausea) and low complexity medical decision making. Documentation of one stable medical problem (HA) is low risk on the risk table. Discussing the case with another healthcare provider gets two points under the data section for MDM. This is level three 99213 history and medical decision making complexity for established outpatient clinic visits. Notice the volume of documentation matters much less than the quality of what is written to support the E/M charge appropriate for the visit.
In my discussions above, I have detailed several examples of the minimum documentation required to meet compliance for level three established patient clinic visits. This is not my patient population in the hospital, however, this well may be common in the outpatient world for a clinic full of mostly healthy adults. For hospitalists, most observation status patients in the hospital these days are much more complex than what a level 3 established clinic patient progress note would support. When would a hospitalist bill an established patient clinic procedure code in the hospital setting?
In my discussions above, I have detailed several examples of the minimum documentation required to meet compliance for level three established patient clinic visits. This is not my patient population in the hospital, however, this well may be common in the outpatient world for a clinic full of mostly healthy adults. For hospitalists, most observation status patients in the hospital these days are much more complex than what a level 3 established clinic patient progress note would support. When would a hospitalist bill an established patient clinic procedure code in the hospital setting?
USING ESTABLISHED PATIENT CLINIC CODES IN THE HOSPITAL SETTING
The CPT® medical billing code group 99211-99215 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances. I have previously discussed all the possible CPT® admission codes that could be used in the hospital setting These established patient clinic and other outpatient visit codes are included as possibilities. I have provided a detailed discussion of that decision tree analysis at the link provided just above. However, I will discuss the pertinent portions of that analysis here.
The attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may apply as well.
But what codes should a consultant use? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from code group 99211-99215 for their initial encounter and all subsequent care visits (including the day of discharge) IF the patient has been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty within the previous three years, unless documentation supports the use of critical care codes or until the patient becomes inpatient status.
If the patient has not been seen in the last three years by the same physician or partner physician in the same group and exact same specialty, the consultant should use the new patient clinic code group 99201-99205 on their initial date of service and then choose a code from the established outpatient code group 99211-99215 for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician.
The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In that case, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services.
The attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may apply as well.
But what codes should a consultant use? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from code group 99211-99215 for their initial encounter and all subsequent care visits (including the day of discharge) IF the patient has been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty within the previous three years, unless documentation supports the use of critical care codes or until the patient becomes inpatient status.
If the patient has not been seen in the last three years by the same physician or partner physician in the same group and exact same specialty, the consultant should use the new patient clinic code group 99201-99205 on their initial date of service and then choose a code from the established outpatient code group 99211-99215 for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician.
The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In that case, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services.
DISTRIBUTION OF ESTABLISHED PATIENT CARE CODES
What is the distribution of CPT® code 99213 relative to other levels of service in this medical code group? The graph below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services. You can find these charts and graphs starting on page 9 of the link provided here. As you can see, between 2001 and 2010, the distribution of established patient office visits has shifted higher. The proportion of level four 99214 and level five 99215 reimbursements has increased by 15% and 2% respectively, while the proportion of level three 99213 services billed for payment has decreased by 8% between 2001 and 2010. On an absolute percentage basis, in 2010, CPT® code 99213 was being billed 46% of the time, down from 53% of the time ten years previously.
Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99213 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99213 was billed 100,268,652 times in 2011 with allowed charges of $6,790,211,816.94 and payments of $4,709558,960.68.
RVU VALUE
How much money does a CPT® 99213 pay? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99213 is worth 1.44 total RVUs for facility services and 2.05 total RVUs for non-facility. The work RVU for 99213 is valued at 0.97. A complete list of RVU values on common hospitalist E/M codes is provided at the attached URL. What is the Medicare reimbursement for CPT® code 99213? In my state, a CPT® 99213 pays about $48 (facility) and $68 (non-facility) in 2016. The dollar conversion factor for one RVU in 2016 is $35.8043.
My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.
LINK TO E/M REFERENCE CARD POST
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