#Office outpatient visit update
#Office outpatient visit code

If you've met the requirements for outpatient office E/M an office visit can be billed based on MDM in addition to the Medicare AWV. If a patient presents for a Medicare Annual Wellness Visit (AWV) and follow-up for chronic conditions, what are the documentation requirements for the E/M? This is similar to the rules defining who qualifies as a 'new patient.' An external physician or QHP is an individual who is not in the same group practice as you, or is in a different specialty or subspecialty. 'External' means records, communications and/or test results from an external physician or QHP, or external facility or health care organization. What does 'external' mean for purposes of reviewing data as part of MDM? An additional 5 minutes was spent on tobacco cessation counseling, discussing the importance of quitting, options for medications and a quit plan. Example (for billing 99213-6) : A total of 25 minutes was spent on this visit, with 20 minutes spent reviewing previous notes, counseling the patient on DM and HTN, ordering tests, refilling meds, and documenting the findings in the note. The time for each service must be carved out of the total time. Make sure to document time separately for each of those services in order to bill for them separately. If I am leveling the visit based on total time and have also provided additional time-based services (e.g., advance care planning, tobacco cessation counseling, etc.) how do I document time for those services? Documentation of an A/P is also important in establishing medical necessity and maintaining continuity of care. If the A/P is not documented and the total time is ambiguous or missing, the visit may be unbillable. If you document both MDM and total time, you can level the visit based on whichever is more advantageous, but you still must present documentation. The A/P may provide additional information that will allow your visit to be leveled if the time statement does not have enough information. Yes, an A/P should always be documented for each visit. If I am leveling the visit based on total time, do I still need to document an assessment and plan (A/P)? Document the actual time spent precisely.

#Office outpatient visit code

Do not document a time range (even though the CPT code description identifies a time range for each E/M code). Use your documentation to justify the medical necessity for the level of service that is being billed. The physician or QHP's documentation needs to justify the time spent for the visit. Documenting these components helps maintain continuity of care and assists other care team members. Although history and physical exam are no longer required to level the visit, they are still important components in establishing medical necessity, supporting medical decision making, and providing high-quality care. Since history and physical exam are no longer required to level the visit, should I still document these elements? The previous E/M guidelines will continue to apply to inpatient services. No, at this time they only apply to outpatient E/M office visits (CPT 99202-99215).

#Office outpatient visit update

The American Medical Association (AMA) has started working on revising other E/M codes, but there is no update yet from the AMA about when those revisions will take effect.ĭo these E/M changes apply to inpatient services? All other outpatient services, including consultations and emergency visits, will continue to use the same key elements for leveling visits. No, these changes only apply to outpatient E/M office visits (CPT codes 99202-99215). Here are some answers to common questions about the changes:ĭo these E/M changes apply to any other outpatient services? History and exam components will no longer be necessary to support coding levels. Physicians and other qualified health professionals (QHP) will be able to code visits based solely on medical decision making (MDM), or solely on total time. Documentation and coding requirements for outpatient evaluation and management (E/M) office visits will change starting Jan.