established patient office visit cpt code

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E/M Coding and Billing Res...
Office/Outpatient E/M Visi...

Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

Download the Office E/M Coding Changes Guide (PDF)

CPT 99211, 99212, 99213, 99214, 99215 – Established patient office visit

CPT CODE and Description

CPT 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. Billing Instructions: Bill 1 unit per visit.

CPT 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Typically, 15 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

CPT 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit. CPT 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 moderate to high severity. Typically, 40 minutes are spent face-toface with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:

1. History 2. Examination 3. Medical decision-making.

When billing office or other outpatient services for established patients, two of the three key components must be fully documented in order to bill (other than 99211). When counseling and/or coordination of care dominates (more than 50 percent) the physician patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Current Procedural Terminology (CPT) codes and requirements

99211 – 5 minutes (average)

• Patient presenting with minimal problems • Three components not required

99212 – 10 minutes (average)

• Problem focused history. Documentation needed: • Chief complaint • Brief history of present illness • Problem focused examination. Documentation needed: • Limited examination of the affected body area or organ system • Medical decision making that is straightforward. Documentation needed (two of three below must be met or exceeded): • Minimal number of diagnoses or management options • None or minimal amount and/or complexity of data to be reviewed • Minimal risk of significant complications, morbidity and/or mortality

99213 – 15 minutes (average)

• Expanded problem focused history. Documentation needed: • Chief complaint • Brief history of present illness • Problem pertinent review of systems • Expanded problem focused examination. Documentation needed: • Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s) • Medical decision making that is of low complexity. Documentation needed (two of three below must be met or exceeded): • Limited number of diagnoses or management options • Limited amount and/or complexity of data to be reviewed • Low risk of significant complications, morbidity and/or mortality

99214 – 25 minutes (average)

• Detailed history. Documentation needed: • Chief complaint • Extended history of present illness • Extended review of systems • Pertinent past, family and/or social history • Detailed examination. Documentation needed: • Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s) • Medical decision making that is of moderate complexity. Documentation needed (two of three below must be met or exceeded): • Multiple number of diagnoses or management options • Moderate amount and/or complexity of data to be reviewed • Moderate risk of significant complications, morbidity and/or mortality

99215 – 40 minutes (average) • Comprehensive history. Documentation needed: • Chief complaint • Extended history of present illness • Complete review of systems • Complete past, family, and social history • Comprehensive examination. Documentation needed: • A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or eight or more organ system(s) • Medical decision making that is of high complexity. Documentation needed (two of three below must be met or exceeded): • Extensive number of diagnoses or management options • Extensive amount and/or complexity of data to be reviewed

• High risk of significant complications, morbidity and/or mortality An important guideline to remember when reporting office visits other than counseling and coordination of care is that only two of the three key components must be reported.

The following is a summary of the requirements for codes 99211 – 99215.

99211: 5 minutes and may not require the presence of a physician 99212: 10 minutes A problem focused history A problem focused examination Straight forward decision making 99213: 15 minutes An expanded problem focused history An expanded problem focused examination Medical decision making of low complexity 99214: 25 minutes A detailed history A detailed examination Medical decision making of moderate complexity

99215: 40 minutes A comprehensive history A comprehensive examination Medical decision making of high complexity

History and physical examination skills and documentation guidelines we were taught in medical training tend to produce a very high quality of medical care. But these do not always meet the guidelines in the multiple medical record components that are required by CPT coding system for E/M coding. To be more efficient and improve reimbursements, physicians must have a better understanding of the Current Procedural Terminology requirements. Future discussions in this section of the AHS website will include a comprehensive discussion of the three key components of CPT coding: History, Examination, and Medical Decision Making, as well as a review of the importance of understanding the Nature of the Presenting Problem in ensuring proper coding. The fourth quarterly future topic in this series will be devoted to the International Classification of Diseases (ICD – 9-CM) coding.

History type ofpatient type of history details of History new est. HPI ROS other history

99211 M.D. presence not required, minimal problem, typically 5 minute service 99201 99212 problem focused brief (1-3 elements) 99202 99213 exp. prob. focused brief (1-3 elements) prob. pertinent (1 system) 99203 99214 detailed ext. (=4 elements) extended (2-9 systems) pertinent (1 area) 99204 comprehensive ext. (=4 elements) complete (=10 systems) complete (= 2 areas) 99205 99215 comprehensive ext. (=4 elements) complete (=10 systems) complete (= 2 areas)

Examination type ofpatient type of exam details of Examination new est.

99211 exam may not be necessary 99201 99212 problem focused limited – affected area or organ system 99202 99213 exp. prob. focused limited – affected area / organ system + other related / symptomatic areas 99203 99214 detailed extended of affected area / organ system + related / symptomatic areas 99204 comprehensive general multi-system exam or complete exam of single organ system 99205 99215 comprehensive general multi-system exam or complete exam of single organ system Medical Decision Making type ofpatient type of details of Medical Decision Making new est. decision making # of diagnoses / management options amount/complexity of data risk of complications / morbidity / mortality

99211 may not require medical decision making 99201 straightforward minimal minimal minimal 99202 99212 straightforward minimal minimal minimal 99203 99213 low complexity limited limited low 99204 99214 moderate complex. multiple multiple moderate 99205 99215 high complexity extensive extensive high

Note: for new patients, all three key components must meet or exceed the above requirements for a given level of service; for established patients, two of the three key components must meet or exceed the requirements. Details of History Details of Examination HPI elements (8): ROS systems (14): body areas: organ systems: location symptoms (e.g. cough) head, including face constitutional quality eyes neck (vital signs, general)

severity ears/nose/throat/mouth chest, inc. breasts, axillae eyes duration cardiovascular abdomen ears, nose, throat, mouth timing respiratory genitalia, groin, buttocks cardiovascular context gastrointestinal back, including spine respiratory modifying factors genitourinary each extremity gastrointestinal assoc. signs/symptoms musculoskeletal genitourinary integumentary musculoskeletal other history areas neurologic integumentary (req. for 99203/14 & up) psychiatric neurologic past history endocrine psychiatric family history hematologic/lymphatic hematologic/lymphatic social history allergic/immunologic /immunologic

• four additional factors may be considered in determining the appropriate code (level of service) for a visit: 1. nature of the presenting problem (minimal, self-limited/minor, low, moderate, or high severity) 2. coordination of care with other health care professionals * 3. counseling * 4. time – see chart below for “typical” time spent face-to-face with patient/family for the various levels of service 5 min. 10 min. 15 min. 20 min. 25 min. 30 min. 40 min. 45 min. 60 min. new patient 99201 99202 99203 99204 99205 est. patient 99211 99212 99213 99214 99215 * when counseling or coordination of care comprises more than 50% of the visit or service rendered, time is the key factor in determining the appropriate code and the total time spent should be clearly documented.

Frequently asked questions CPT 99213 and 99214

99213 CPT code requirements?

Time – 20-29 minutes of the total time is spent on the date of the encounter

Key Components – Based on MDM alone (2 out of 3 elements). Elements are

Number and complexity of the problem
Amount and/or Complexity of Data to be Reviewed and Analyzed (must meet 1 of the 2 categories)
Risk of Complications and/or Morbidity or Mortality of Patient Management

how often can CPT 99392 be billed?

It can be billed once in a year (at least it should have completed 11 months)

is CPT 99213 covered by medicare?

Yes, covered by Medicare

how often can CPT 99223 be billed?

It can be billed only once per day by the same physician or physicians of the same specialty from the same group of practice.

how often can 99213 be billed?

There is no specific limitation for billing this code

when to use CPT code 99213

Only when the patient is an established patient seen by the same physician of the same specialty from the same group practice

difference between 99213 and 99214?

when to use CPT code 99214?

how often can you bill 99214?

is 99214 covered by medicare?

what is the difference between CPT code 99214 and 99215?

CPT 99214 cost?

Non-facility – $129.77
Facility – $98.97

Patient Status

The status of a patient must be verified for correct coding and billing. There are four categories:

1. New: A new patient is someone who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.

2. Established: An established patient is someone who has received any professional service from a physician in group or same specialty within the past three years.

1. New patients, consultations, inpatient and emergency room visits MUST have all three key components (e.g., History, Examination and Medical Decision Making) to meet an E/M level of service.

2. Established patients and subsequent inpatient visit MUST have two out of three key components (e.g., History, Examination and Medical Decision Making) to meet the appropriate level of E/M service.

Time can be the controlling factor to qualify for a particular level of E/M visit. This can occur when counseling and/ or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face in the office or outpatient setting, floor/unit time in the hospital or nursing facility). For example, if 25 minutes was spent face-to-face with an established patient in the office and more than half of that time was spent counseling the patient or coordinating his or her care, CPT® code 99214 should be selected.

New Patient

E/M codes are divided into two categories, new or established patient for office visits. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.

CPT code and Allowed amount.

This is just an approximate allowed amount and for the exact amount , reach out to the insurance.

Established Patient

99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician . Usually the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.

Example: A patient returns to the office three days later to have PPD test evaluated and for instructions on self-administration of TNF-alpha inhibitor. The RN evaluates the PPD test and informs the rheumatologist that it is negative. The rheumatologist instructs RN to proceed with teaching patient self-administration of TNF-alpha inhibitor and provides RN with prescription for TNF-alpha inhibitor to give to patient. RN instructs patient on selfadministration of TNF-alpha inhibitor and patient is scheduled to return to office next week to give self TNF-alpha inhibitor injection under supervision of RN. The patient will return for routine E/M follow-up visit in one month.

The physician does not personally see patient during this visit, but is present in the office suite

99212 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components:

1. A problem-focused history • Chief complaint • Brief history of present illness 2. A problem-focused examination • A limited exam of affected body area or organ system 3. Straightforward medical decision making • Minimal number of diagnoses/management options • Minimal (or no) amount/complexity of data obtained, reviewed and analyzed • Minimal risk of complications/morbidity/mortality

Counseling and/or 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 self-limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

Example: This is a follow-up visit for a 35-year-old male seen before for pain and loss of motion in his right shoulder. He returns for follow-up after a course of medication, an intraarticular injection and physical therapy. Review of test results and a physical examination reveal that the patient is now better. The patient is told to return only if a new problem occurs. 99213 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components :

1. An expanded problem-focused history • Chief complaint • Brief history of present illness • Problem pertinent system review 2. An expanded problem-focused examination • A limited exam of affected body area or organ system and other symptomatic or related organ systems 3. Medical decision making of low complexity • Limited number of diagnoses/management options • Limited amount/complexity of data obtained, reviewed and analyzed • Low risk of complications/morbidity/mortality

Example: A 68-year-old woman comes in for a follow-up office visit; she has polymyalgia rheumatica maintained on chronic low-dose corticosteroids. The history reveals no increase in the shoulder or hip pain. There has been some mild weight gain and bruising while on the medication. A limited examination was performed. The patient was instructed on long-term prognosis of PMR and steroid side effects. Laboratory tests were ordered. 99214 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components:

1. A detailed history • Chief complaint • Extended history of present illness • Problem pertinent system review extended to include a review of a limited number of additional systems • Pertinent past, family, and/or social history directly related to the patient’s problems 2. A detailed examination • Extended exam of affected body area(s) and other symptomatic/related organ system(s) 3. Medical decision making of moderate complexity • Multiple number of diagnoses/management options • Moderate amount/complexity of data reviewed • Moderate risk of complications/morbidity/mortality

Counseling and/or 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 moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

99215 Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of the following three key components:

1. A comprehensive history • Chief complaint • Extended history of present illness • Review of systems which is directly related to the problem(s) identified in the history of present illness plus a review of all additional body systems. • Complete past, family, and/or social history

2. A comprehensive examination • A general multi-system exam or a complete exam of a single organ system

3. Medical decision making of high complexity • Extensive number of diagnoses/management options • Extensive amount/complexity of data obtained, reviewed and analyzed • High risk of complications/morbidity/mortality

Counseling and/or 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 moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family

New & Established Office Visits

New Patient Office and Consultations:

• Must have documentation inall three categoriesof history, exam, and medical decision making to meet level of service OR

• May satisfy criteria by documentation of time when counseling and/or coordination of care is greater than 50% of the total time taken Definition of a “New Patient”

• CMS Definition:

“One who has not received a face-to-face evaluation and management service or procedure from a physician, or colleague of the same specialty (or subspecialty; AMA 2012) who belongs to the same group practice within the past 3 years. New patient status does not apply to admissions, critical care services or ER.”

• Based on Payor credentialing

• Mid-levels are non-designated (specialty) in most states Established Patients:

• Must have documentation inat least two categoriesof history, exam and medical decision making OR

• May satisfy criteria by documentation of time when counseling and/or coordination of care is greater than 50% of the total time taken

D. Use of Highest Levels of Evaluation and Management Codes Contractors must advise physicians that to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).

The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.

Summary of Criteria – Established Patient Established CPTCode (2 of 3 required) History Exam Decision

99211 (5 min) 1 HPI 1 body area or organ systems Straightforward

99212 (10 min) (1 stable condition or self limiting problem) 1 HPI 1 body area or organ systems Straightforward

99213 (15 min) (2 stable conditions or acute uncomplicated illness or injury) 2-3 HPI and 1 ROS 2-4 Body areas or organ systems Low

99214 (25 min) (worsening problem, undiagnosed new problem, or several existing problems) 4 or more elements or status of 3 chronic conditions; 2 to 9 ROS; and 1 PFSH 5-7 body areas or organ systems Moderate

99215 (40 min) (one or more chronic illness w/severe exacerbation, life threatening) 4 or more elements or status of 3 chronic conditions; 10 to 14 ROS; and 2 PFSH 8 or more organ systems High

Counseling and Coordination of Care

Clinical Example

Established Patient Times • 99211 = 5 • 99212 = 10 • 99213 = 15 • 99214 = 25 • 99215 = 40

Example of C & CC

• Patient returns for MRI results and discussion of treatment regarding her breast cancer. We discussed the role of chemotherapy and benefits of the current clinical trials. Patient understands side effects and consents to start treatment next week. Spent a total of 20 minutes with the patient, over half of which was counseling on treatment options.

• 99213 based on time.

Preoperative and Postoperative Billing Errors

Preoperative and postoperative billing errors occur when E&M services are billed with surgical procedures during their preoperative and postoperative periods. ClaimCheck bases the preoperative and postoperative periods on designations in the CMS National Physician Fee Schedule. For example, if a provider submits procedure code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making [10 minutes]) with a DOS of 11/02/08 and procedure 27750 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation) with a DOS of 11/03/08, ClaimCheck will deny procedure code 99212 as a preoperative visit because it is submitted with a DOS one day prior to the DOS for procedure code 27750. Services Provided by Ancillary Providers

Claims for services provided through telemedicine by ancillary providers should continue to be submitted under the supervising physician’s NPI (National Provider Identifier) using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician and documented in the same manner as face-to-face services. Coverage is limited to procedure codes 99211 or 99212, as appropriate.

Primary Care Treatment and Follow-up Care for Mental Health and Substance Abuse

Initial primary care treatment and follow-up care are covered for members with mental health and/or substance abuse needs provided by primary care physicians, physician assistants, and nurse practitioners. Wisconsin Medicaid will reimburse the previously listed providers for CPT (Current Procedural Terminology) E&M (evaluation and management) services (procedure codes 99201-99205 and 99211-99215) with an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code applicable for mental health and/or substance abuse services. As a reminder, these services may be eligible for HPSAs (Health Professional Shortage Areas) and pediatric enhanced reimbursements. Refer to the latest edition of CPT or to the CMS (Centers for Medicare and Medicaid Services) 1995 or 1997 Documentation Guidelines for Evaluation and Management Services via the CMS Web site for guidelines for determining the appropriate level of E&M services.

Since counseling may constitute a significant portion of the E&M services delivered to a member with mental health and/or substance abuse diagnoses, providers are required to fully document the percentage of the E&M time that involved counseling. This documentation is necessary to justify the level of E&M visit. Claims for services delivered by ancillary staff under the direct, on-site supervision of a primary care physician must be submitted under the NPI (National Provider Identifier) of the supervising physician. Coverage and reimbursement are limited to CPT code 99211 or 99212 as appropriate. Tobacco Cessation Drugs and Services

Tobacco cessation services are reimbursed as part of an E&M (evaluation and management) office visit provided by a physician, physician assistant, nurse practitioner, and ancillary staff. Services must be one-on-one, face-to-face between the provider and the member. BadgerCare Plus does not cover group sessions or telephone conversations between the provider and member under the E&M procedure codes. Tobacco cessation services covered under BadgerCare Plus and Wisconsin Medicaid include outpatient substance abuse services or outpatient mental health services, as appropriate. Tobacco cessation services covered under the BadgerCare Plus Core Plan include medically necessary E&M visits, as appropriate.

Ancillary staff can provide tobacco cessation services only when under the direct, on-site supervision of a Medicaid-enrolled physician. When ancillary staff provide tobacco cessation services, BadgerCare Plus reimburses up to a level-two office visit (CPT (Current Procedural Terminology) code 99212). The supervising provider is required to be listed as the rendering provider on the claim.

Health Professional Shortage Area-Eligible Procedure Codes Providers may submit claims with HPSA modifier “AQ” (Physician providing a service in a HPSA). While the modifier is defined for physicians only, any Medicaid HPSA-eligible provider may use them with the following procedure codes

Bundling Guidelines of Consult code to 99211 – 99215 – bcbs insurance

BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212 99242 to 99212 99243 to 99213 99244 to 99214 99245 to 99215

Office Visits – Office services provided on an emergency basis (99058) are considered mutually exclusive to the primary services provided.

Office visit (99211) is considered mutually exclusive to 95115-95117(allergen immunotherapy). Separate reimbursement is not allowed for mutually exclusive services. Pap Smears – Obtaining a pap smear is integral to the office visit. This includes both preventive and routine office visits. Separate reimbursement is not allowed for Q0091.

Pathologists – Claims submitted by pathologists (provider specialty 29) for clinical interpretation of laboratory results will be allowed for codes 83020, 84165, 84166, 84181, 84182, 85060, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, and 87207. Pathology interpretation of all other codes in the 80002-87999 range is considered integral to the laboratory test. Separate reimbursement is not allowed for integral services.

Pulse Oximetry – Pulse oximeters are considered incidental to office visits or procedures. Separate reimbursement is not provided for incidental procedures.

Respiratory Treatments – Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB devise is considered mutually exclusive to an office visit. Separate reimbursement is not provided for mutually exclusive services.

Robotic Surgical Systems – Payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.

STAT or After Hours Laboratory Charges – Additional charges for STAT or after hours laboratory services are considered an integral part of the laboratory charge.

Surgical Supplies – Surgical supplies will be considered incidental to Surgical; Laboratory; Inpatient, Outpatient or Office Medical Evaluation and Management; and Consultation services. Surgical dressings applied in the provider’s office are considered incidental to the professional services of the health care practitioner and are not separately payable. Surgical dressings billed in the provider’s office (place of service 11) will be denied.

Surgical trays and miscellaneous medical and/or surgical supplies are generally considered incidental to all medical, chemotherapy, surgery, and radiology services, including those performed in the office setting.

Supplies (except those related to splinting and casting) are considered components of the 0, 10, and 90- day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure.

Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit.

Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.

Transvaginal Ultrasound – Transvaginal ultrasound (76830) is considered mutually exclusive to a hysterosonography with or without color flow Doppler (76831). Venipuncture – Refer to policy “Code Bundling Rules Not Addressed in Claim Check.”

Vision Services – Determination of refractive state (92015) performed incidental to a medical eye exam is permissible and may be covered when performed outside of any global allowance and subject to member benefits.

X-Rays – When single view and double view chest X-Rays are billed together (71010 and 71020), only the double view X-Ray is allowed. When the entire spine, survey study is billed (72082) with cervical spine films (72040), thoracic spine films (72070) or lumbosacral spine films (72100) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view XRay code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowable per X-Ray.

Examples of billable and non-billable prolonged services follow with CPT 99213 and 99212

Billable Prolonged Services

A physician performed a visit that met the definition of an office visit CPT code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills CPT code 99213 and one unit of code 99354.

EXAMPLE 2 A physician performed a visit that met the definition of a domiciliary, rest home care visit CPT code 99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills CPT codes 99327, 99354, and one unit of code 99355.

A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician bills CPT code 99215 and one unit of code 99354. ?

Non-billable Prolonged Services

A physician performed a visit that met the definition of visit code 99212 and the total duration of the direct face-to-face contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct face-toface service did not meet the threshold time for billing prolonged services.

A physician performed a visit that met the definition of code 99213 and, while the patient was in the office receiving treatment for 4 hours, the total duration of the direct face-to-face service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.

A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

Finally, you should remember that Medicare contractors will not pay (nor can you bill the patient) for prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls). These are Medicare covered services and payment is included in the payment for other billable services.

Medical billing code 99213

This Medical billing code 99213 address audits the method code definition, advancement note illustrations, RVU values, national dispersion information and clarifies when this code ought to be utilized as a part of the healing center setting. CPT remains for Current Procedural Terminology. This code is a piece of a group of therapeutic charging codes depicted by the numbers Medical billing code 99213 speaks to the center (level 3) office or other outpatient set up office patient visit and is a piece of the Healthcare Common Procedure Coding System (HCPCS). This technique code address for built up office patient visits is a piece of a complete arrangement of CPT® addresses composed without anyone else. I am a board affirmed inner solution doctor with more than ten years of clinical hospitalist involvement in a group hospitalist project giving doctor administrations to a vast local healing center framework. I have composed my accumulation of assessment and administration (E/M) addresses throughout the years to help doctors and other non-doctor professionals (medical caretaker experts, clinical attendant masters, confirmed medical caretaker birthing specialists and doctor partners) comprehend the unpredictable and obsolete universe of healing facility and center based coding prerequisites.

These unique addresses and going with assets are utilized independent from anyone else to stay consistent with the guidelines and regulations of the Centers for Medicare and Medicaid Services (CMS). All my CPT® addresses (counting Medical billing code 99213 and CPT® 99215) have been composed in one simple to-discover asset on Pinterest and can be gotten to by clicking this connection. You don’t should be a Pinterest part to access any of my CPT® method addresses. As you ace these CPT® E/M technique codes, recall that, you have a commitment to ensure your documentation underpins the level of administration you are submitting for installment. The volume of your documentation ought not be utilized to decide your level of administration. The subtle elements of your documentation are what matter most. Moreover, the E/M administrations aide says the consideration you give must be “sensible and vital” and all passages ought to be dated and contain a CMS characterized neat mark or mark confirmation, if important.

99213 MEDICAL CODE DESCRIPTION

Office or other outpatient visit for the assessment and administration of a built up patient, which requires no less than two of these three segments: An extended issue centered history; An extended issue centered examination; Medical choice making of low unpredictability. Directing and coordination of consideration with different suppliers or organizations are given predictable the way of the problem(s) and the understanding’s and/or family’s necessities. For the most part, the exhibiting problem(s) are of low to direct seriousness. Doctors ordinarily burn through 15 minutes up close and personal with the patient and/or crew.

A built up patient is characterized as a person who has gotten proficient administrations from a specialist or another specialist of precisely the same and subspecialty who fit in with the same gathering practice inside of the previous three years.

This medicinal charging code can be charged in light of time when certain necessities are met. Documentation of time is not required to stay consistent with CMS regulations. In the event that charged without time as a thought, CPT® 99213 documentation ought to be bolstered by the 1995 or 1997 E/M rules referenced previously. The three critical coding parts for a built up outpatient center note are the:

Physical Exam

Medicinal Decision Making Complexity

For all settled office patient charging codes (99211-99215), the most noteworthy recorded two out of three above parts decides the right level of administration code. Contrast this and the prerequisite for the most elevated reported three out of three above parts for new office patient consideration experiences (99201-99205). Once more, just the most elevated two out of three parts are expected to decide the right level of tend to CPT® 99213. The accompanying examination points of interest the base prerequisites important to stay agreeable with CPT® 99213. Furthermore, as with all E/M experiences, an eye to eye experience is constantly required. Then again, on account of outpatient center codes, Medicare allows episode to charging, where the administration is given by somebody other than the doctor. On the off chance that sure prerequisites are met, the doctor may gather 100% of passable charges in these circumstances. Administrations charged occurrence to are charged under the doctor’s supplier number.Medical billing code 99213 Extended issue centered history: Requires just 1-3 parts for the historical backdrop of present sickness (HPI) OR documentation of the status of THREE unending restorative conditions. No past restorative history or social history or family history is required. Just 1 issue apropos audit of frameworks (ROS), that asks about the framework identified with the issue recognized in the HPI, is required.

Extended issue centered examination: 1997 rules require documentation of no less than six components recognized by a slug in one or more organ systems(s) or body area(s). 1995 rules require a restricted examination of the influenced body region or organ framework and other symptomatic or related organ system(s). The CMS E&M guide on pages 31 and 32 portrays the adequate body ranges and organ frameworks on physical exam.

Therapeutic choice making of low intricacy (MDM): This is split into three parts. The 2 out of 3 most elevated amounts in MDM are utilized to decide the general level of MDM. The level is dictated by a perplexing arrangement of focuses and hazard. What are the three parts of MDM and what are the base required number of focuses and hazard level as characterized by the Marshfield Clinic review instrument?

Finding (2 focuses)

Information (2 focuses)

Danger (low);

The restorative choice making point framework is exceedingly mind boggling. I have a point by point reference to it on my E/M pocket cards depicted underneath. These cards offer me some assistance with understanding what kind of consideration my documentation underpins. I convey these trick sheet cards with me at all times and reference every one of them day long. As a hospitalist who performs E/M benefits solely, these cards have kept me from under and over charging a huge number of times throughout the most recent decade.

CLINICAL EXAMPLES OF 99213

What are some advancement note documentation illustrations for a CPT® 99213, the level 3 built up patient visit in an office or other outpatient setting? Most specialists utilize the subject, goal, appraisal and arrangement (SOAP) note group. A 99213 note could resemble this:

S) No more stomach torment (1 HPI). Gentle Nausea (1 issue relevant ROS)

O) 120/80 Tmax 98.9 (three fundamental signs = one slug) guts no masses; lungs clear; heart no mumble; legs no edema; skin no impulsive. (no less than 6 downright shots)

A) Nothing required

P) Nothing required

In this sample history (subjective) and physical (goal) meet the prerequisites to get paid for a 99213. Keep in mind, the most elevated 2 out of 3 segments decide the largest amount of administration for set up patients in the center or other outpatient setting. Do note that connecting an ICD code to a CPT® restorative code is required for all visits submitted to CMS for repayment. Accordingly, most advance notes ought to give no less than one ICD code to unmistakably show a reason for the visit. I think this is important to meet the sensible and vital edge, unless that can be derived from other diagram documentation. Medicare wouldn’t like to pay for specialists to discuss legislative issues with their patients. There must dependably be an endorsed ICD code connected with the CPT® restorative code when charged to CMS and most other insurance agencies.Medical billing code 99213

Here is another clinical case of a SOAP note for a CPT® 99213 set up patient facility visit:

S)No SOB (1 issue appropriate ROS)

O) 120/80 Tmax 98.9 (three basic signs = one projectile) guts no masses; lungs clear; heart no mumble; legs no edema; skin no impulsive. (no less than 6 all out shots)

A)HTN-stable, no progressions arranged.

DM-stable, no progressions arranged.

COPD-stable, no progressions arranged. (the status of three endless medicinal conditions set up of HPI)

As you probably are aware, reporting the status of three incessant restorative conditions can substitute for the HPI. Include one issue correlated audit of framework and this is the base history

The going to doctor ought to look over the perception gathering of therapeutic codes 99218-99220 for the introductory experience, 99224-99226 for perception status subsequent codes, and 99217 for perception release. Under specific circumstances, same day concede and release charging codes 99234-99236 or basic consideration method

Medical code 99214 , if charged effectively, can build income for the practice. By just utilizing CPT code 99212 and CPT code 99213 numerous suppliers are losing a huge number of dollars in true blue income yearly. Which can be maintained a strategic distance from with the right charging of the 99214 E/M Code.

The CPT meaning of another patient experienced unpretentious changes in 2012. Sadly, CMS did not change their definition to stay adjusted to these progressions. This distinction in dialect has brought on awesome disarray for some qualified human services specialists attempting to stay agreeable with the mind boggling standards and regulations of E&M.

Another patient is one who has not got any expert administrations from the doctor/qualified social insurance proficient or another doctor/qualified medicinal services proficient of precisely the same and subspecialty who fits in with the same gathering practice, inside of the previous three years.

CPT Code 99214,99213 E/M Coding Established Office Patient Correctly for Medicare Reimbursement

Medical code 99214 is allocated to the therapeutic administration that agrees to the accompanying necessities:

The patient is a set up one, which means is not their first visit.

It must be an outpatient visit, which means it must not consolidate a day of clinic time.

It must meet or surpass to of the accompanying three focuses:

A point by point therapeutic history

A point by point therapeutic exam

A therapeutic choice that involves moderate multifaceted nature.

The seriousness of the issue that conveys the patient to the center must be from a moderate to a high one. 5. What’s more, last, the specialist and the patient ought to have a greatest of 25 minutes acknowledgment.

Medical code 99214

CPT code 99214 Increases Medicare Revenue

Medicare and other Insurance are satisfied to pay the lesser cash to suppliers on the off chance that they (the specialists) are willing to under utilize the CPT code 99214. The way to utilizing this code accurately is to comprehend the best possible use and the parts required to completely catch the most out of the majority of your experiences. As a supplier, you will be compensated the your rewards for all the hard work when you set aside an ideal opportunity to take in the parts of this code and utilize it appropriately.

When you consider CPT code 99214 it has a higher return rate connected to it, be that as it may, it must fall under the domain of a moderate unpredictability to a high seriousness issue. The doctor, if utilizing time as a variable more likely than not spent no less than 25 minutes in an eye to eye situation with the patient. In any case, the time part is just an aide and not totally required if the segments are incorporated into the visit and the required therapeutic need is available. The doctor must have the capacity to outfit the a few ranges which incorporate history, physical exam and therapeutic choice making with the best possible documentation when petitioning for the CPT code 99214.

The patient experience, made out of an itemized history, nitty gritty patient exam and moderate many-sided quality in the restorative choice making will legitimize the utilization of CPT code 99214 the length of the medicinal need is evident.

For instance, you have a set up office tolerant with hypertension, diabetes and a background marked by dyslipidemia who you are seeing on follow up in the workplace. Under the 1997 rules you can utilize three constant and stable conditions to fit the bill for the higher code inside of the history segment.

Archive the drugs and the survey of frameworks alongside the best possible past medicinal, family and social history and the first segment is met. Record the best possible physical exam utilizing proper organ framework approach six regions with two slugs each and you have met the necessity for the many-sided quality on this region.

As of right now, actually you have come to the level 4 criteria since there just should be two out of three parts required for a built up patient.

On the other hand, we feel that it is hard to not have a restorative choice making segment so we incorporate that into our advancement note. You can record the lab results for the patient and further set the visit to qualify at the higher code. For whatever length of time that the restorative need is available to legitimize the work done amid the visit the coding can be at the larger amount.

99214 versus 99213 CPT Codes Billing

In above Example, most suppliers will code the illustration as a CPT 99213, on the other hand, the qualifiers are available for the higher 99214 code.

While assessing three distinctive medicinal issues, for example, Hypertension, Diabetes and Hyperlipidemia, utilizing the 1997 standards, you have met the restorative need segment also, because of the need to screen these illnesses and help the patient with his/her control.

Be that as it may, meeting the correct criteria required to code the experience will empower a restorative biller to get the prizes for the his vocation and his practice. It additionally get to be vital, becaue now days Medical Billing and Coding Business are confronting potential cuts in the repayments for the administrations the bill.

established patient office visit cpt code

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List With Office Visit CPT Codes (New & Established Patients)

The CPT codes for office visits can be found in the CPT manual; under range CPT 99202 until 99205 for office visits of new patients . For office visits of established patients, you can use range 99211 to CPT code 99215. We also included CPT 99070 in case you need to bill extra supplies/materials for office visits and CPT code 99072 if extra staff and supplies were needed during a Public Health Emergency.

CPT Code 99070

Long description of CPT 99070 : Supplies and materials [except spectacles] provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided].

Short description: Extra supplies/materials for office visit.

CPT Code 99072

Long description of CPT 99072 : Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service[s], when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

Short description: Extra supplies and staff time for office visits during Public Health Emergency.

CPT Code 99202

Long description of CPT 99202 : Office or other outpatient visit for the evaluation and management of a new patient , which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

Short description: 15-29 minute office visit for new patient evaluation and management.

CPT Code 99203

Long description of CPT 99203 : 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.

Short description: 30-44 minute office visit for new patient evaluation and management.

CPT Code 99204

Long description of CPT 99204 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spend on the date of the encounter.

Short description: 45-59 minute office visit for new patient evaluation and management.

CPT Code 99205

Long description of CPT 99205 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code+ selection, 60-74 minutes of total time is spent on the date of the encounter.

Short description: 60-74 minute office visit for new patient evaluation and management.

CPT Code 99211

Long description of CPT 99211 : Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional

Short description: Short office visit for established patient management.

CPT Code 99212

Long description of CPT Code 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 spent on the date of the encounter.

Short description: 10-19 minute office visit for established patient management.

CPT Code 99213

Long description of CPT 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.

Short description: 20-29 minute office visit for established patient management.

CPT Code 99214

Long description of CPT 99214 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spend on the date of the encounter.

Short description: 30-39 minutes office visit for established patient management.

CPT Code 99215

Long description of CPT 99215 : Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

Short description: 40-54 minutes office visit for established patient management .

https://www.aapc.com/codes/cpt-codes-range/99211-99215/

https://www.aapc.com/codes/cpt-codes-range/99202-99205/

https://www.aapc.com/codes/cpt-codes/99070

https://www.aapc.com/codes/cpt-codes/99072

CPT Codes For Remote Therapeutic Monitoring Services

Below is a list summarizing the CPT codes for remote therapeutic monitoring services. CPT Code 98975 CPT 98975 describes the initial set-up and patient education on using equipment for remote therapeutic monitoring (e.g., therapy adherence, therapy response). CPT Code 98976 CPT 98976 describes remote therapeutic monitoring, such as therapy adherence and therapy response, with device(s)…

CPT Codes For Non-Invasive Cerebrovascular Arterial Studies

Below is a list summarizing the CPT codes for non-invasive cerebrovascular arterial studies. CPT Code 93880 CPT 93880 describes a complete bilateral study of a duplex scan of extracranial arteries. CPT Code 93882 CPT 93882 describes a duplex scan of extracranial arteries with either a unilateral or limited study. CPT Code 93886 CPT 93886 describes…

CPT Codes For Incision Procedures On The Kidney

Below is a list summarizing the CPT codes for incision procedures on the kidney. CPT Code 50010 CPT 50010 describes renal exploration, not necessitating other specific procedures. CPT Code 50020 CPT 50020 describes the open drainage of a perirenal or renal abscess. CPT Code 50040 CPT 50040 describes nephrostomy and nephrotomy with drainage. CPT Code…

How To Use CPT Code 47740

CPT 47740 describes the creation of a connection between the gallbladder and small intestine to allow for the drainage of bile in the presence of a blockage. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples. 1. What is CPT Code 47740? CPT 47740…

How To Use CPT Code 66983

CPT 66983 describes the procedure of intracapsular cataract extraction with insertion of an intraocular lens prosthesis in a one-stage procedure. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples. 1. What is CPT Code 66983? CPT 66983 is used to describe a…

TheraThink.com

A mental health billing service, cpt code 99213: the definitive guide [+2024 reimbursement rates].

It’s time to learn about CPT Code 99213 for Evaluation and Management services of an established patient in your private practice!

This guide will teach you what defines procedure code 99213, what distinguishes it from other evaluation and management codes (99213 vs 99212), and will also give you information about cpt code 99213 reimbursement rates for insurance.

Article Index

CPT Code 99213 Description
Reimbursement Rates
Time Length

CPT Code 99213 Definition:

Evaluation and management of an established patient in an office or outpatient location for 15 minutes.

Procedure Code 99213 Time Length:

15 minutes in length, as determined by their level of risk and complexity of treatment.

If a client has a more complex treatment plan requiring additional time, bill evaluation and management CPT Code 99214 or 99215 to designating higher risk and complexity of services.

CPT Code 99213 Description:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components to be present in the medical record:

An expanded problem focused history
An expanded problem focused examination
Medical decision making of low complexity

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.

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.

99212 vs 99213 vs 99214 vs 99215: Evaluation and Management

Which evaluation and management code between procedure codes 99212, 99213, 92214, and 99215 correspond to the complexity and risk for that treatment situation:

Low for code 99213
Moderate for 99214
High for 99215

Procedure Code 99213 Billing Tip!:

You want to select 99213 when two of the three components of medical treatment are met and the complexity of treatment is low.

When the complexity increases, the timeline for treatment increases, as does reimbursement rates, and so you’d be best to bill with a E/M cpt code that is of higher complexity like 99214 or 99215.

If you are unsure which code to use, be it 99213, 99214, or otherwise, feel free to reach out to us at TheraThink to get help with your mental health insurance billing .

Established Client Psychiatry Medicare Rates for 2019 and 2020

CPT Code 99213 Reimbursement Rates [2024]

It’s important to note that CPT Code 99213 reimbursement rates vary by location, insurance company, network status, panel, license, and more. Rates quoted here are example rates that help show generally differing rates across different insurance companies.

99213 Reimbursement Rates – Medicare 2024: $89.39

Other Medicare rates for CPT code 99213 are $81.62, in WA in King County, so it depends on the locality. Source

99213 Reimbursement Rates: – Medicaid:

99213 commercial insurance reimbursement rates according to medicare.

Here are the rates that Medicare believes are the commercial insurance rates for these services (this is not the Medicare rate for 99213):

It’s important to note that these rates are adjusted down and reflect what Medicare has deemed are average rates for most psychiatrists across the United States. These rates are adjusted by Medicare.

Some insurance companies only pay 15% over the Medicaid rate in their state, whereas others pay 45%, 60%, 80%, 85% on top of their state’s medicaid rate.

You can see these rates vary across insurance companies. It’s important to keep this in mind when working on your mental health insurance credentialing applications. Ask colleagues about rates if you dare, or reach out for help from us about suggestions!

Evaluation and Management Codes: New vs Established Clients

Unlike 99212 through 99215, 99202 through 99205 describe newly established clients being seen for evaluation and management services. Code 99213 should only be used with established clients you have already seen for an intake session (CPT Code 90792).

Getting Help Billing

Is all of this gibberish? We established a mental health billing service at TheraThink to help you stay away from all this jargon so you can focus on what you do best. Reach out now for more information on our services.

https://www.aap.org/en-us/professional-resources/Research/Medicaid%20Reimbursement%20Reports/medicaid_reimbursement_2015_iowa.pdf
https://thehappyhospitalist.blogspot.com/2013/07/99213-CPT-Procedure-Code-Description-Examples-RVU-Distribution.html?m=1https://coder.aapc.com/cpt-codes/99213
https://www.cms.gov/About-CMS/Story-Page/CY-19-PFS-Final-Rule-PPT.pdf
https://www.palmettogba.com/Palmetto/Providers.Nsf/files/Video_Part_B_CPT-Codes-for-Evaluation-and-Management-Office-Visits-Established.pdf/$File/Video_Part_B_CPT-Codes-for-Evaluation-and-Management-Office-Visits-Established.pdf
https://correctcodechek.decisionhealth.com/Cpt/Detail.aspx?Code=99213
https://www.cgsmedicare.com/partb/mr/pdf/99213.pdf
https://www.cgsmedicare.com/partb/mr/pdf/99214.pdf
https://www.cgsmedicare.com/partb/mr/pdf/99215.pdf
https://med.noridianmedicare.com/documents/10534/18795567/Washington%2C%20Area+02%2C%202019+Medicare+Part+B+Fee+Schedule+PDF
https://med.noridianmedicare.com/web/jfb/fees-news/fee-schedules/mpfs

2021 2022 99213 99213 reimbursement cpt code 99213

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Introduction
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Higher scores indicate greater patient preference. The reference is the solid color background. Whiskers indicate SDs.

a Statistically significant when compared with the reference ( P < .05).

All physician types in each background are compared with all physician types in the reference category (solid color background).

eFigure. Photographs of the 7 Environmental Types

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Houchens N , Saint S , Kuhn L , Ratz D , Engle JM , Meddings J. Patient Preferences for Telemedicine Video Backgrounds. JAMA Netw Open. 2024;7(5):e2411512. doi:10.1001/jamanetworkopen.2024.11512

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Patient Preferences for Telemedicine Video Backgrounds

1 Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
2 Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
3 Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
4 Department of Pediatrics, University of Michigan Medical School, Ann Arbor

The COVID-19 pandemic prompted rapid adoption of telemedicine. Most physicians had no training on effective webside manner, 1 including their physical environment. Strategies for optimal visual elements during telemedicine visits have been based on professional expertise and not empirical data. 2 , 3 The preferred environment from which a physician conducts video visits remains unknown. Thus, we assessed patient preferences for various visual backgrounds during video visits.

This cross-sectional study was approved by the University of Michigan and Veterans Affairs Ann Arbor Healthcare System institutional review boards. Survey completion implied consent. We followed the STROBE reporting guideline.

Data collection occurred between February 22 and October 21, 2022. Participants included a random sample of adults 18 years or older who had completed an in-person or virtual outpatient visit within the prior year at either institution. Race and ethnicity data were collected but not reported to protect confidentiality (given the majority of participants were White) and because this study was not powered to use these data in the analyses. Additional participants included registrants from a digital health research recruitment platform.

Paper and electronic surveys included photographs of a model physician in different environments (eFigure in Supplement 1 ). Patients selected their preferred environment, and a composite score was calculated across 6 domains (how knowledgeable, trustworthy, caring, approachable, and professional the physician appeared, and how comfortable the physician made the respondent feel). Scores ranged from 1 to 10, with higher scores indicating greater preference.

Descriptive statistics were used to tabulate results. Mean composite score differences were assessed using linear regression, with a solid color background as the reference category. Differences in preferred environment for all physician types were assessed using multinomial logistic regression. Questions assessed 4 separate physician types (new and established primary care and new and established specialty); these questions were analyzed together, and standard errors were adjusted for repeated measures within participants. Statistical analyses were performed using SAS, version 9.4 (SAS Institute Inc). A 2-sided P < .05 was considered significant.

A total of 1213 patients returned surveys (response rates: university paper survey, 30%; veteran paper survey, 27%; university electronic survey, unknown); 637 patients (54.1%) were 65 years or older; 626 (53.3%) self-identified as female and 544 (46.3%) as male; and 28 (2.4%) self-identified as Asian, 91 (7.9%) as Black, 978 (84.7%) as White, and 57 (4.9%) as multiracial or other (including American Indian, Alaska Native, Arab or Arab American, Native Hawaiian, and other). The solid color background garnered a mean (SD) composite score of 7.7 (2.1). Other professional backgrounds ( Figure 1 ) received similar scores. The physician office displaying diplomas was rated highest across 5 domains (mean [SD] composite score, 7.8 [1.9]). Significantly lower mean (SD) scores were calculated for the bedroom (7.2 [2.3]; P = .02) and kitchen (7.0 [2.5]; P = .002) environments.

The physician office displaying diplomas scored highest for all physician types. Considering all physician types together (a single respondent could choose a different preferred background for different physician types) and comparing with a solid color background (14.4%), respondents significantly preferred physician office (18.4%; P = .007) and physician office displaying diplomas (34.7%; P < .001) but significantly fewer preferred the bedroom (3.5%; P < .001) and kitchen (2.0%; P < .001) backgrounds ( Figure 2 ).

In this study, two-thirds of participants preferred a traditional health care setting background for video visits with any physician type, with physician office displaying diplomas rated highest. This background scored similarly to other traditional environments, whereas bedroom and kitchen were significantly less preferred.

Numerous studies have found nonverbal communication to be a modifiable determinant of patient trust and satisfaction. 4 - 6 To our knowledge, this is the first study to examine patient preferences for the physician’s visual background. Limitations include low response rates for mailed surveys, emphasis on only 1 aspect of telemedicine encounters, and a focus on 2 institutions in 1 geographic region, which may affect generalizability. Nonetheless, findings suggest that patients may harbor specific preferences regarding the background environment used during telemedicine visits. Health care systems should prioritize performing telemedicine visits within a traditional office or examination room environment.

Accepted for Publication: March 12, 2024.

Published: May 15, 2024. doi:10.1001/jamanetworkopen.2024.11512

Corresponding Author: Nathan Houchens, MD, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Rd, MC 111, Ann Arbor, MI 48105 ( [email protected] ).

Author Contributions: Dr Houchens had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Houchens, Saint, Kuhn, Meddings.

Acquisition, analysis, or interpretation of data: Houchens, Kuhn, Ratz, Engle, Meddings.

Drafting of the manuscript: Houchens, Kuhn, Engle.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Houchens, Ratz.

Administrative, technical, or material support: Kuhn, Engle, Meddings.

Supervision: Houchens, Saint, Meddings.

Conflict of Interest Disclosures: None reported.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: The authors thank Michele Mazlin, BS (University of Michigan), for uncompensated work in preparing and editing photographs for the survey instrument. Photographs of physicians were provided by Michigan Photography, University of Michigan. Photographs of background environments were provided by Michigan Medicine, University of Michigan.

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Telehealth in Washington State

Telehealth care takes place where the patient is located at the time of the appointment. This means that practice laws and requirements in the patient's location regulate healthcare professionals' practice. Washington state has passed laws related to telehealth and telemedicine, addressing definitions; regulations; scope of practice; licensing, credentialing, and privileging requirements; consent; prescribing; privacy and security; billing and reimbursement; and documentation and coding. These laws are codified into one or more Revised Code of Washington (RCW), which new legislation can amend. The Washington Administrative Code (WAC) may provide additional guidance.

This page provides information on telehealth-related Washington state legislation, RCWs, and WACs. It includes links to guiding documents and standards of practice for various health care professionals. It also provides information on payer policies; telehealth and telemedicine billing and reimbursement; and COVID-19 pandemic-related guidance, waiver, and temporary changes.

Please refer to the original source documents for current information. Do not regard the information provided here as legal advice. It is for informational purposes only. Always consult with legal counsel when addressing legal and regulatory considerations.

Establishes key definitions
Requires coverage parity under specified conditions
Specifies eligible patient locations
Allows originating sites to charge a facility fee
Discusses credentialing
Adds home as an originating site
Establishes the WA State Telehealth Collaborative (WSTC)
Sets standards for the safety and effectiveness of services
Makes store and forward technology eligible for "credential by proxy."
Defines home as any location determined by the person receiving the services.
Clarifies language on credentialing and privileging in telemedicine services.
Requests those providing clinical telemedicine services to complete a telemedicine training effective January 1, 2020.
Directs the WSTC to make online telemedicine training available.
Moves telemedicine training effective date to January 1, 2021.
Makes the training required and adds an exemption for MDs and DOs.
Outlines training topics and clarifies definitions.
Requires reimbursement for telemedicine services at the same rate as in-person services, with some exceptions.
Immediately effective due to the public health emergency.
Directs WSTC to study store-and-forward technology and specifies foci of the study.
Requires behavioral health administrative services organizations and managed care organizations to reimburse providers for behavioral health services provided via telemedicine or store-and-forward technology under specified conditions.
Allows practitioners licensed by other states or territories to hold consultations via telemedicine with practitioners licensed in Washington with responsibility to diagnosis and treat patients in Washington.
Defines and allows audio-only telemedicine services with established patients who have had at least one in-person visit in the last year. Takes effect January 1, 2023.
Describes possible violations that would result in disciplinary actions.

More about Telehealth in Washington State

Current laws, revised code of washington (rcws) that pertain to telehealth and telemedicine, rcw 70.41.020: definitions..

RCW 48.43.735: Reimbursement of health care services provided through telemedicine or store and forward technology. : health plans.

RCW 41.05.700: Reimbursement of health care services provided through telemedicine or store and forward technology. : employer health plans.

RCW 74.09.325: Reimbursement of a health care service provided through telemedicine or store and forward technology—Medicaid manages care plans

RCW 74.09.658: Home health—Reimbursement—Telemedicine. : Medicaid managed care plans.

RCW 70.41.230: Duty of hospital to request information on physicians, physician assistants, or advanced registered nurse practitioners granted privileges. : credential-by-proxy

RCW 28B.20.830: Collaborative for the advancement of telemedicine—Reports—Open meetings.

RCW 43.70.495: Telemedicine training for health care professionals.

RCW 71.24.335: Reimbursement for behavioral health services provided through telemedicine or store and forward technology—Coverage requirements.

RCW 18.71.030: Exemptions.

RCW 18.57.040: Licensing exemptions.

RCW 18.130.180: Unprofessional conduct. : Unprofessional Conduct.

Washington Administrative Codes (WACs) related to telehealth and telemedicine

WAC 182-531-1730 – Telemedicine

WAC 182-531-0100 - Scope of coverage for physician-related and health care professional services—General and administrative

WAC 182-535-1050 – Teledentistry

WAC 182-551-2010 - Within the context of Medicaid's home health program

WAC 182-551-2125 - Delivery of home health services through telemedicine

WAC 182-551-2040 - Medicaid Home Health Services Face-to-Face Encounter Requirements

Telemedicine guidance: consent-to-treat

Appropriate use of Telemedicine GUI2014-03) (PDF)

Recommends practitioners obtain and document informed consent for telemedicine encounters, including:

reasonable understanding by all parties of the enabling technologies utilized,
their capabilities and limitations, and
a mutual agreement that they are appropriate for the circumstances;
provider credentials.

Physician-Related Services -- Health Care Professional Services Billing Guide (PDF)

Requires written informed consent from clients when using store-and-forward technology. The consulting provider must also be identified. See page 90. Physician-Related Services -- Health Care Professional Services Billing Guide (PDF) ,

Behavioral-health-policy-and-billing-COVID-19 (PDF)

Requires clients to be informed when using a non-HIPAA compliant technology (allowed during the COVID-19 pandemic). Addresses using mail to obtain written consent, use of electronic signatures, and verbal consent.

COVID-19 Public Health Emergency Response and 42 CFR Part 2 Guidance (PDF)

Addresses providing Substance Use Disorder (SUD services via telemedicine/telehealth technologies and compliance with 42 CFR part 2. Washington Health Care Authority encourages providers to use email and scan, the mail, or electronic signature functionality to obtain written consent for the release of records.

Telemedicine guidance: prescribing

Relaxations regarding signed prescriptions for scheduled substances during COVID-19 emergency) (PDF)

On April 21, 2020, the Pharmacy Quality Assurance Commission temporarily eased regulations on practitioners who prescribe Schedule II substances due to the COVID-19 public health emergency The Commission increased the amount of time practitioners have to deliver signed prescriptions when authorizing an emergency prescription of a Schedule II substance to the pharmacy. Also allowed the "signed prescription" requirement via paper, electronic transmission, facsimile, photograph, or scanned copy.

Telemedicine and authorizing medical cannabis

Addresses the use of telemedicine following an in-person physical examination to authorize the use of cannabis for medical purposes, and for subsequent physical examinations for the purposes of renewing an authorization.

Appropriate use of Telemedicine GUI2014-03 (PDF)

The Washington Medical Commission addresses standards for using telemedicine for treatment, including issuing a prescription, and prescribing DEA-controlled substances.

Drug Monitoring in the context of Mental Health Services (PDF)

Addresses drug monitoring as part of a qualified telemedicine visit.

Telemedicine guidance: health professions

Washington State Department of Health Professions webpage

Telehealth Resources: Washington State Department of Health

Includes definitions, appropriate use of telemedicine/telehealth, and licensure guidance.

Health Professions with Authority to Provide Telehealth Services (PDF)

Requires a Washington state license to provide health care to patients in Washington unless:

the provider is operating under the Uniform Emergency Volunteer Health Practitioners Act under chapter 70.15, or
an interstate compact that allows practice in Washington with a Washington compact privilege.

Provides general information for health care professionals authorized to provide telehealth services. Note: Does not apply to providers in a Direct Indian Health Service Clinic, Tribal Clinic, or Tribal Federally Qualified Health Center (FQHC). These providers may be licensed in any state per federal law.

Note : Washington is a member of the Interstate Medical Licensure Compact and the Physical Therapy Compact .

Licensure related to telemedicine/telehealth during COVID-19 pandemic

FAQ on telemedicine and licensing during the COVID-19 pandemic
Federation of State Medical Boards document regarding states' licensure requirements during the COVID-19 pandemic (PDF)

T elehealth training

Beginning Jan. 1, 2021 health care professionals providing clinical services through telemedicine need to complete a telemedicine training. Exceptions to this requirement are provided for physicians and osteopathic physicians.

Telemedicine guidance: health profession-specific information

Advanced Practice Nursing

Department of Health Nurse Care Quality Assurance Commission Advisory Opinion (draft) (PDF)

Addresses advanced registered nurse practitioner (ARNP) performance of telehealth services, license/credential requirements to provide telehealth services to individuals/patients located in Washington, and outside of Washington. (See information re Nursing Telehealth practice below).

Applied Behavior Analysis

WAC 182-531A-1200 Defines services provided via telemedicine.

Chiropractors

COVID-19 Message Telemedicine Policy and Temporary Continuing Education (PDF)

Describes how teledentistry is defined, supervised, regulated and disciplined by the Dental Commission and provides general technology principles.

WAC 182-535-1050 Defines teledentistry.

Apple Health (Medicaid) dental emergency coverage related to COVID-19 pandemic (PDF)

Dietitians Providing Telehealth for Established Patients During the COVID-19 Declared Emergency (PDF)

Addresses dietitians licensed in Oregon or Idaho providing treatment to Washington residents using telehealth.

Hearing and Speech

Board of Hearing and Speech Telepractice Guidelines (PDF)

Addresses definitions of telehealth and standards of care.

Home Health Program – Medicaid.

WAC 182-551-2010: Definitions.

WAC 182-551-2040: Face-to-face encounter requirements.

WAC 182-551-2125: Delivered through telemedicine.

WAC 246-335-610 : Defines telemedicine, telehealth in the hospice context.

Naturopathic Medicine

Board of Naturopathy Appropriate Use of Telemedicine (PDF)

Clarifies the appropriate use of telemedicine in naturopathic practice and outline the Board of Naturopathy's expectations of naturopathic physicians when using telemedicine technologies.

Nursing Telehealth Practice

Department of Health Nurse Care Quality Assurance Commission Advisory Opinion (PDF)

Allows appropriately trained and competent registered nurses, licensed practical nurses, nursing technicians, and nursing assistants-certified/nursing assisted-registered to perform telehealth nursing care using telehealth technologies within their legal scope of practice, regulatory requirements, and practice standards. Addresses credentialing and cross-state telehealth practice requirements.

See above for information for Advance Practice Nurses

Occupational Therapists and Occupational Therapy Assistants

WAC 246-847-176: Telehealth.

Specifies that a Washington license is required to deliver occupational therapy via telehealth.

Board of Optometry Telehealth Guideline (PDF)

Clarifies the appropriate use of telehealth in optometric practice, and to outline the Board of Optometry's expectations of optometric physicians when using telehealth technology.

Pharmacists and Pharmacy Interns

Pharmacists can provide pharmacy services via telehealth as long as the services provided fit within an element of the practice of pharmacy as defined in RCW 18.64.011(28) and the pharmacist complies with Pharmacy Commission rules in Chapter 246-945 WAC .

WAC 246-945-430(5)

of a pharmacist to perform the monthly self-inspection requirement for pharmacies that store, dispense, and deliver drugs without a pharmacist on-site.

WAC 246-945-001(44)

Requires the intern to practice under the immediate supervision of a pharmacist.

Physical Therapists

Use of telehealth in the practice of physical therapy WAC 246-915-187 .

A Guide to Providing Treatment Via Telehealth for PTs and PTAs in Washington

Washington is a member of the Physical Therapy Compact .

Washington State Medical Association website: COVID-19 and Telehealth

Medicaid scope of coverage for physician-related and health care professional services: WAC 182-531-0100.

Washington is a member of the Interstate Medical Licensure Compact .

FAQ on telemedicine and licensing during COVID | Washington Medical Commission

Federation of State Medical Boards regarding licensure during the COVID-19 pandemic (PDF)

Check the Washington Medical Commission web site for possible new guidance.

CR-101 : Telemedicine)

The Washington Medical Commission (WMC) will consider rulemaking to address the practice of physicians and physician assistants engaging in telemedicine with Washington patients, possibly including requirements for licensure; recordkeeping requirements; establishing a patient-practitioner relationship; prescribing issues; and standard of care. For more information see the WMC update Spring 2021 .

Sex Offender Treatment Providers

WAC 246-930-010: General definitions.

Speech Language Pathologists

Board of Hearing and Speech Telepractice Guidelines (PDF) .

Substance Use Disorder Professionals (SUDP)

SUDP employer/facility rules may restrict telehealth. For example, a significant number of SUDPs work in licensed behavioral health agencies (BHA). BHAs are subject to rules requiring “in-person” or “face-to-face” interactions with clients. WAC 246-341-0610(1)(a), WAC 246-341-0200, WAC 246-341-0712(3), WAC 246-341- 0820(2)(a), WAC 246-341-0910, WAC 246-341-0915, and WAC 246-341-1110(2)(b). These rules are currently waived in response to the COVID-19 pandemic. WSR 20- 07-0105.

Veterinarians

WAC 246-933-200 : Veterinary-client-patient relationship.

Addresses use of veterinary telemedicine during the COVID-19 pandemic. (PDF)

Location and Practice Specific Guides

Location Specific Guides

Federally Qualified Health Center (FQHC) Billing Guide (PDF)

FQHCs are authorized to serve as an originating site for telemedicine services and are paid an originating site facility fee, or as a distant site. Provides further specifics regarding billing and claims.

Rural Health Clinic (RHC) Billing Guide (PDF)

RHCs are authorized to serve as an originating site for telemedicine services and are paid an originating site facility fee, or as a distant site. Provides further specifics regarding billing and claims.

School-Based Health Care Services (SBHS) (PDF)

Under the SBHS program, the Washington Health Care Authority pays for services provided through telemedicine as outlined in this billing guide. Addresses provider eligibility and requirements, originating site requirements, and billing information. Also see WAC 182-531-1730 . For updated information regarding how to bill for SBHS during COVID-related school closures and/or distance learning models, see the SBHS COVID-19 FAQ (PDF) , also available on the SBHS webpage.

Tribal Health Billing Guide (PDF)

Allows eligible encounters to be conducted via real-time telemedicine. Refers to WAC 182-531-1730 for telemedicine information.

Practice Specific Guides

Applied Behavioral Analysis (ABA) Billing Guide (PDF)

Defines “telemedicine,” “originating site,” and “distant site,” as it applies to ABA, and how telemedicine may be used for program supervision, family training, and reimbursement eligibility as well as associated billing instructions. For more information see Provider billing guides and fee schedules ; and WAC 182-531A-1200 .

Behavioral Health

RCW 71.24.335 : Reimbursement for behavioral health services provided through telemedicine or store and forward technology—Coverage requirements

Addresses reimbursement for behavioral health services provided through telemedicine or store-and-forward technology to persons under 18 years old - coverage requirements.

Aligns with SB5385.

See also Behavioral Health Policy and Billing-COVID-19 (PDF) - see detailed telehealth eligibility and billing guidance within this document.

Drug Monitoring in the context of Mental Health Services (PDF) . Addresses drug monitoring as part of a qualified telemedicine visit.

Teledentistry

Dental Related Services Program Billing Guide (PDF)

Washington Apple Health clients are eligible for medically necessary covered dental services delivered through teledentistry. References the following.

Dental Quality Assurance Commission Tele Dentistry Guideline (PDF)

Defines “teledentistry” (and associated terms) as the variety of technologies and tactics used to deliver HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store-and-forward technology to deliver covered services within dental care provider's scope of practice to a client at a site other than the site where the provider is located. Also notes that a dentist or authorized dental provider may delegate allowable tasks to Washington State Registered Dental Hygienists (RDHs) and Expanded Function Dental Assistants (EFDAs) through teledentistry, referencing WAC 246-817-525 and WAC 246-817-550. See also Apple Health (Medicaid) dental emergency coverage related to COVID-19 pandemic (PDF) .

Washington Medicaid/Apple Health

Telemedicine & Telehealth Brief (PDF)

Provides an overview of the Health Care Authority telemedicine and telehealth policies; billing guidance; best practices; privacy and HIPAA compliance information; considerations for Substance Use Disorder services; and a resource list.

Telehealth Guidance for Apple Health Clients during COVID-19 pandemic (English version); available in additional languages (PDF) here , (search “telehealth”).

Clinical policy and billing for COVID-19 (PDF)

Electronic signature guidance during the COVID-19 outbreak (PDF)

Provider Billing Guides and Fee Schedules

Physician-Related Services - Health Care Professional Services Billing Guide (PDF)

Defines “telemedicine,” including HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology, and associated requirements; and notes that the Health Care Authority does not cover the following services as telemedicine:

Email, audio only telephone, and facsimile transmissions
Installation or maintenance of any telecommunication devices or systems
Purchase, rental, or repair of telemedicine equipment

Addresses eligibility requirements and provider responsibilities. MCOs cover the delivery of care via telemedicine: follow the MCO policy and billing requirements.

For updated telemedicine/telehealth guidance, see Information about novel coronavirus (COVID-19) | Washington State Health Care Authority found under "Providers, billers, and partners” and then under “Physical health providers

For telehealth policy, billing, or coding questions, contact via email .

Telehealth Information Provided by Healthcare Exchange Plans

Washington State Office of the Insurance Commissioner

Individual and family health plans & premiums

Premera Blue Cross

Updates to Telehealth/Telemedicine Payment Policy | Provider
Coding and Billing of a Telehealth Encounter | Provider
Telehealth Services for Members | Producer

Asuris Northwest Health

COVID-19 telehealth
Bridgespan Health Company-Telehealth

Community Health Network of Washington

CHPW Virtual Care - Washington State Local Health Insurance
COVID-19 Provider Bulletin - Washington State Local Health Insurance

Coordinated Care Washington

Alliance Northwest Health Plan

Coronavirus (COVID-19) Information and Updates : See “Does my health plan cover any type of telehealth and/or virtual doctor visits?”

Kaiser Foundation Health Plan of the Northwest

Kaiser Permanente NW Classic Certificate of Coverage (COC) 2021 (Employees) (PDF)
Kaiser Permanente NW Consumer-Directed Health Plan (CDHP) Certificate of Coverage (COC) 2021 (Employee) (PDF)

Lifewise Health Plan of Washington

Find Care | LifeWise (virtual care)

Molina Healthcare of Washington

COVID Telehealth Billing Policy

PacificSource Health Plans

Telehealth | PacificSource (for members)
Telehealth (PDF)
PacificSource Benefit and Reimbursement Policy (FAQ) (PDF)
Telehealth Reimbursement and Behavioral Health Update

Providence Health Plans

About | Providence
Providence Health Plan - Washington Individual Contract - Providence Columbia Individual & Family Plan (PDF)
Telehealth Virtual Visits | Providence
Telehealth Services During COVID-19 Crisis

Regence BlueCross BlueShield

Virtual care and telehealth services
Verifying coverage of virtual services
Coronavirus (COVID-19)
FEP telehealth options - Provider - REG

United Healthcare of Oregon

Talk to a doctor from home
Telehealth Services
Telehealth visits | UnitedHealthcare

Additional information regarding payer policies may be found at OneHealthPort .

Apple Health Medicaid

Telehealth guidance for apple health clients during covid-19 pandemic.

Telehealth guidance for Apple Health clients during COVID-19 FAQ (English version); Available in additional languages here , (search “telehealth”).

Apple Health clinical policy and billing for COVID-19 (

Provides detailed information regarding Apple Health telehealth-specific policy during the COVID-19 pandemic, eligible telehealth services, and billing and coding guidance including use of appropriate telemedicine/telehealth modifiers. Includes defining “telemedicine” as HIPAA-compliant, synchronous/real-time, audio-video interaction; description of payment parity for “telemedicine” and “telehealth;” COVID-19 pandemic “relaxed regulations” allowing non-HIPAA-compliant non-public-facing telehealth platforms; additional non-“telemedicine” modalities, such as eConsults (asynchronous provider-to-provider consultation), online digital exchange through patient portals, texting and email.

Electronic signature guidance during the COVID-19 outbreak

Physician-Related Services - Health Care Professional Services Billing Guide

Provides updated telemedicine/telehealth guidance published on Washington Health Care Authority's webpage found under “Providers, billers, and partners” and then under “Physical health providers.”

Provider billing guides and fee schedules | Washington State Health Care Authority

Telemedicine & Telehealth brief for COVID-19

Provides an overview of the Washington Health Care Authority telemedicine and telehealth policies; billing guidance; best practices; privacy and HIPAA compliance information; considerations for Substance Use Disorder services; and a resource list.

Health Professional-specific Guidance pertaining to COVID-19 Pandemic

Behavioral Health Policy and Billing during COVID-19 pandemic - see detailed telehealth eligibility and billing guidance within this document.

COVID-19 Message Telemedicine Policy and Temporary Continuing Education

Apple Health (Medicaid) dental emergency coverage related to COVID-19 pandemic

Dietitians Providing Telehealth for Established Patients During the COVID-19 Declared Emergency

Washington State Medical Association “COVID-19 and Telehealth”

Federation of State Medical Boards regarding licensure during the COVID-19 pandemic

School-Based-Health-Care-Services-COVID-19 for updated information regarding how to bill for SBHS during COVID

Veterinary-Client-Patient Relationship Requirements During the COVID-19 Response.

Licensure during COVID-19 Pandemic:

Prescribing over telehealth - guidance.

Relaxations regarding signed prescriptions for scheduled substances during COVID-19 emergency (full text)

On April 21, 2020), the Pharmacy Quality Assurance Commission temporarily eased the regulations on practitioners who prescribe Schedule II substances due to the COVID-19 public health emergency, increasing the amount of time a practitioner has to deliver a signed prescription when authorizing an emergency prescription of a Schedule II substance to the pharmacy. Also allows the "signed prescription" requirement via paper, electronic transmission, facsimile, photograph, or scanned copy.

COVID-19 and Opioid Treatment Programs FAQ

Addresses the use of telemedicine or telephonic services to provide medically necessary services and/or psychosocial counseling services for the continuity of care for OTP clients, and starting a new, not yet admitted opioid use disorder diagnosed individual onto buprenorphine or methadone during the COVID-19 public health emergency.

Washington State Department of Labor and Industries

Temporary Record Review & Telehealth Independent Medical Exams (IME) Policy

Temporary Telehealth Policy When the Worker's Home is the Originating Site

Temporary Telehealth Policy for Naturopathic Physicians

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Latest News

Knowing the rules can help practices receive payments that better reflect the work of the whole health care team.

BETSY NICOLETTI, MS, CPC

Fam Pract Manag. 2024;31(3):9-14

Author disclosure: no relevant financial relationships.

Medical services are usually billed by the individual who performs the service. However, Medicare has two exceptions — “incident to” and “shared services.” These two rules essentially allow physicians to bill for care provided by clinicians and staff who work with them as if the physicians had done it themselves. They're similar rules, but with key differences.

Incident-to services are performed in physician offices or patients' homes, while shared services are performed in facilities such as hospitals or nursing homes. Incident-to services can be performed by either non-physician clinicians (NPCs) or clinical staff as part of the billing physician's professional services, while shared services must be performed by two clinicians (physicians or NPCs) who each could have billed the service on their own. (See “ Incident-to vs. shared services comparison .”)

In either case, though, if the physician is billing, Medicare pays the full physician fee schedule rate, while services billed by NPCs are paid at 85% of that. Some private insurers also allow incident-to billing and shared services billing under rules similar to Medicare's, but this varies by payer.

Shared services rules have changed recently, as CPT has published new definitions (which Medicare has largely adopted, for now). The requirements for incident-to billing haven't changed, but they can be confusing, and because family physicians tend to use incident-to billing more often, a refresher is useful. This article provides that refresher on incident-to billing, as well as an explanation of the changes to shared services billing, and has a set of questions and answers with specific scenarios to help physicians understand when and how to use each of them.

Medicare allows supervising physicians to bill for services that other members of the health care team provide in office or home settings (“incident-to” billing) and bill for services they provide jointly with other clinicians in facility settings (“shared services”).

Some private payers also allow incident-to billing and shared services billing, and CPT has released definitions for shared services.

Shared services are billed by the physician or other clinician who performed the “substantive portion” of the E/M visit, which is easier to determine when using total time.

INCIDENT-TO REFRESHER

Incident-to rules allow a supervising physician to report services performed by NPCs or auxiliary clinical staff as if the physician personally provided them. NPCs are most often physician assistants or nurse practitioners. They're sometimes called “other qualified health care professionals” (QHPs)” or “non-physician practitioners” (NPPs), but in this article we'll refer to them as NPCs. Clinical staff are most often medical assistants or nurses, but could include other professionals who work under physicians' supervision (see “ Definitions ”). Billing for incident-to services under the supervising physician's name and National Provider Identifier (NPI) results in the full reimbursement rate.

DEFINITIONS

Non-physician clinicians (NPCs) or non-physician practitioners (NPPs): Physician assistants and a variety of advance practice registered nurses (e.g., clinical nurse specialists, certified nurse midwives, nurse practitioners, and certified registered nurse anesthetists) who are allowed to bill Medicare directly.

Other qualified health care professional: According to CPT, “A physician or other qualified health care professional is an individual who by education, training, licensure/regulation, and facility privileging (when applicable) performs a professional service within his/her scope of practice and independently reports a professional service. These professionals are distinct from clinical staff.” This includes the NPCs/NPPs above, but also other professionals such as physical therapists and clinical social workers.

Clinical staff member: According to CPT , this is “a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service.” This includes medical assistants and nurses.

NPCs may also use incident-to billing for services clinical staff provide under their supervision. As noted, though, Medicare will pay a lesser rate (85% of the physician fee schedule amount) for incident-to services billed using the NPC's name and NPI on the claim form.

Incident-to services include evaluation and management (E/M) and other services and supplies commonly furnished in medical practices, such as applying a splint, doing an injection, or checking blood pressure at a nurse visit. Incident-to billing does not apply to services with their own statutory benefit categories (i.e., groups of services health plans are legally required to cover), including wellness visits, clinical diagnostic tests, and pneumococcal, influenza, and hepatitis B vaccines.

To bill for a service that an NPC performed under the physician's NPI (at the full physician rate), these requirements must be met:

• The service must be part of a physician's plan of care . The physician sees the patient at a prior encounter and establishes the plan of care. After that, the NPC may see the patient as part of the physician's treatment. (If a subsequent E/M service can be performed entirely by clinical staff, rather than an NPC, the supervising physician may still bill for it as an incident-to service at the full physician rate using E/M code 99211 — the lowest level of E/M. Higher level E/M services must be performed by an NPC or physician.) E/M services for new patients, or new problems for existing patients, aren't eligible for incident-to billing because they are not part of the physician's preexisting plan of care. If an NPC provides these services, they must bill for them under their own NPI (at the 85% rate).

• The service requires direct supervision . The physician, or the physician's covering partner, is in the suite of offices (or patient's home) and immediately able to assist if needed when the NPC performs the service. Medicare rules are generally interpreted as requiring the supervising physician to be in the same or a similar specialty as the NPC performing the service, although the Centers for Medicare & Medicaid Services (CMS) doesn't specifically say this. Likewise, CMS does not specifically define supervision beyond the physician being “in the suite of offices,” but some payers interpret it to mean not separated by a set of stairs or elevator.

• The NPC must be an expense to the practice , either employed, leased, or contracted.

• The physician must stay involved in the plan of care , but CMS does not describe exactly what this entails. It could mean alternating visits with the NPC or periodically seeing the patient. Simply signing off on the record alone is less compelling as documentation, and there is no Medicare requirement for co-signature. NPCs can provide documentation that supports incident-to billing by noting in their assessment that the visit was part of the physician's plan of care and that the physician was in the office. But CMS does not specifically require this.

• The NPC must be enrolled in Medicare , whether billing directly or incident to the physician, according to U.S. Department of Health and Human Services guidance. 1

SHARED SERVICES

Until recently, only Medicare defined shared services. But CPT added its own definition in 2021 and expanded it in 2024. (See “ CPT vs. CMS shared services comparison .")

Shared services are E/M services that a physician and NPC perform jointly in a facility setting, such as inpatient and outpatient hospital buildings, emergency departments, and nursing homes. Shared services may not be performed in physician offices that are not part of a facility setting. The place of service (POS) code is key to shared services billing. 2 For example, hospital outpatient clinics that use POS 19 (on campus) or 22 (off campus) can bill for shared services, whereas physicians' offices that use POS 11 cannot. (It's the opposite with incident-to services, which can be billed with POS 11, but not POS 19 or 22.)

Both clinicians must be enrolled in Medicare and able to perform E/M services on their own (a physician may not share E/M services with a social worker or dietitian, for example, because those professionals don't have E/M in their scope of practice). 3

To bill for E/M as a shared service, both clinicians must participate in the patient's care on the same calendar day. The identity of both clinicians must be included in the encounter note, but only the billing clinician is required to sign and date the medical record. That clinician then submits the claim using HCPCS modifier FS (“split [or shared] evaluation and management visit”) for Medicare.

Remember that when the physician bills for the shared service, Medicare pays 100% of the physician fee schedule allowance, but when an NPC bills, it results in payment of only 85%. So, it makes sense to bill under the physician's NPI when possible. But under both Medicare and CPT rules, physicians may only do this if they perform the “substantive portion” of the service.

Billing based on time . If you're billing for E/M based on total time, determining who provided the substantive portion of the visit is pretty straightforward: The clinician who accounted for more than half the visit's total time (face-to-face and non-face-to-face time combined) performed the substantive portion of the service. Thus, both clinicians should document their own time, and if the physician's time is greater than half, the service should be billed under the physician's NPI. The only complicating factor with time-based coding is that if the physician and other clinician meet to discuss the patient, or see the patient together, only one of them can count those minutes — they can't double-count them.

Billing based on MDM . If you're using medical decision making (MDM) to code an E/M service, determining who performed the substantive portion is significantly more complicated. There's no quick and clear way to do it, but here is some guidance based on both CPT and CMS rules.

MDM is defined by three elements: the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of morbidity and/or mortality from additional diagnostic testing or treatment. In 2024, CPT added this instruction: “performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) who made or approved the management plan for the number and complexity of problems addressed at the encounter take responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM. If a practice codes the visit based on medical decision-making (MDM), the practitioner who performs the problems addressed and risk portions of the visit reports the service.” 4

The key takeaways are this:

The physician or NPC who evaluates the problems and determines and takes on the risk of the additional testing and treatment of those problems (two of the three MDM elements) meets the “substantive portion” threshold to qualify as the billing clinician.

CPT states that the billing clinician “made or approved the management plan.” It does not state that the billing clinician must personally document the plan.

There is one twist. If you use data to select the level of E/M service and include Category 2 data (an independent interpretation of an image or tracing) or Category 3 data (discussion with an external health care professional about management or test interpretation), the billing clinician must perform that portion of the service. 4 Category 1 data (ordering and/or reviewing unique test results, reviewing notes, or using an independent historian) does not need to be performed by the billing clinician because this work is included in the formulation of the diagnosis and plan.

Because of the complicated nature of determining who should be the billing clinician using MDM, CMS has said that in the future it intends to require that clinicians only use time to determine who performed the substantive portion of shared services. But CMS delayed that change for the third year in a row in its 2024 Physician Fee Schedule final rule, instead saying it would follow the new CPT definition for now.

CMS also said this about shared services: “Although we continue to believe there can be instances where MDM is not easily attributed to a single physician or NPP when the work is shared, we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support the billing of the visit.” 5

CMS does not explicitly say what the billing physician needs to document and what the NPP (or NPC) could document instead. Therefore, although CPT's guidance seems to indicate that an attestation statement is acceptable (“made or approved the management plan”), it would be prudent for physicians to personally document MDM when billing Medicare for shared services under their NPI.

PAYMENTS THAT BETTER REFLECT THE WHOLE HEALTH CARE TEAM

Clearly, the rules governing incident-to billing and shared services billing are not always simple. But the list of questions and answers should help clarify some common scenarios.

Having a basic understanding of when shared services and incident-to rules apply allows physicians to receive payments that better reflect the actual work their practices are doing, especially as team-based care increases.

Q: Dr. Taylor sees a patient for hypertension and sets a plan for the patient to return to see the nurse practitioner (NP) to titrate the medication in two weeks. When the patient comes back to see the NP, Dr. Taylor is out of the office, but her partner Dr. Jackson is in the office. Do we bill this latest visit under Dr. Taylor or Dr. Jackson?

A: Dr. Jackson. Bill under the supervising physician who is in the office and able to provide assistance if needed.

Q: A physician sees an established patient for an acute problem, a sprained ankle. Six months later, the patient slips and re-sprains the ankle and the practice's physician assistant (PA) sees the patient. Can the physician bill this as an incident-to service?

A: No, this acute condition is a new problem and should be billed by the PA.

Q: Can you bill incident to if using time to determine the level of evaluation and management?

A: Yes. You can bill incident to if using time or medical decision making.

Q: If a physician and an advance practice registered nurse (APRN) are billing for a shared service E/M visit based on time, do each of them need to document their time?

A: Yes. The clinician who accounted for more than 50% of the time bills for the service, so both the physician and the APRN must document their time. (They can't double-count time if they both see the patient together or meet to discuss the patient.)

Q: Working in an outpatient hospital department, a physician and PA each perform part of an office/other outpatient visit. It is follow up for an urgent care visit over the weekend. The patient has an acute, uncomplicated condition, and a prescription medicine is given for cough control. The physician personally interprets the chest x-ray from the urgent care visit. Under the shared services rules, who should report the E/M service and what is the correct level of service?

A: Two of the three medical decision-making elements are moderate: amount and complexity of data (independent interpretation) and risk (prescription drug management). It is, therefore, a level-4 E/M visit. The physician performed the independent interpretation of data and, therefore, may bill for the visit.

Q: Can we bill for shared services for nursing facility visits?

A: Yes. Skilled nursing visits that use place of service 31 qualify because that is considered a facility location. But nursing facility services in place of service 32 (mostly rehab providers) do not because that is considered a non-facility location. Also, shared services may not be performed for visits mandated to be done by a physician.

Advanced practice registered nurses, anesthesiologist assistants, and physician assistants. Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network. MLN901623; March 2022.

Place of service code set. CMS. Updated September 2023. Accessed March 13, 2024. https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets

Medicare Claims Processing Manual, Ch. 12, Sec. 30.6.18A. CMS 100-04; rev. 12461. Jan. 18, 2024. Accessed March 14, 2024. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

CPT 2024 Professional Edition . American Medical Association; 2023.

CMS-1784-F. CMS. Nov. 16, 2023. Accessed March 14, 2024. https://www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-federal-regulation-notices/cms-1784-f

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