Basic Coding Tips
Date: 07/07/2024
- With the advent of the new outpatient codes in 2021, you can code based on time or medical decision making.
- Billing based on time is the most straightforward method of coding outpatient visits. This includes total time on the calendar day of the visit. This time should be clearly documented in your clinic note.
CPT- New patient
Time range
CPT- established patients
Time range
99203
30-44
99213
20-29
99204
45-59
99214
30-39
99205
60-74
99215
40-54
- When billing based on medical decision making, you need to factor in 3 elements: number/complexity of problems addressed, data reviewed, and risk of patient management. The higher of the 2 out of 3 elements will support the code level.
- Examples of data reviewed for headache may include imaging, which should be documented in your note and include your interpretation, “ I personally reviewed the MRI from X date and it showed . . . . “ Also document any labs reviewed, tests ordered, any interprofessional communication with other physicians, or other historians that may be related to that visit in order to support a moderate or high level CPT code (level 4 or 5).
- It is important to understand the Medical Decision Making table from the AMA which outlines the levels of CPT codes. See table here.
- Prescription drug management is a moderate level of patient management.
- G2211 is a new code implemented in January 2024 that is an add on code for outpatient evaluation and management visits which applies to new or established visits.
- There is no additional documentation needed for the G2211 add on code so long as it’s indicated that chronic management is being performed for a complex medical diagnosis longitudinally.
- Additional coding tips from the AHS Practice Management Committee:
About the Author
Dr. Raissa Villanueva is a practicing general neurologist and headache medicine specialist. She is Chief of Headache and General Neurology and Medical Director of Compliance at the University of Rochester Medical Center in Rochester, NY. She is also Co-chair of the Practice Management Committee at AHS and a member of the Coding and Payment Policy Subcommittee at the American Academy of Neurology. Her areas of expertise are in practice management, ambulatory operations, billing and coding.
