Basics of CPT code 99205
As part of the continued effort to simplify documentation requirements and reduce burden, the CPT Editorial Panel revised the E/M documentation guidelines for several other E/M services in January 2023. The 2023 changes are largely an expanded application of the 2021 office visit E/M guideline changes. CPT code 99205, 99202, 99203 & 99204 are revised as per new update. As per the new update below things have been updated;
History and physical exam elements are not so important
The patient history and physical exam elements are no longer components of E/M code level selection. Physicians should still document the history and physical exam as medically appropriate. These elements may still be necessary for clinical practice, professional liability (i.e., malpractice) reasons, and quality measurement.
Revisions to the MDM table – Very Important element
The Medical Decision Making table has been revised to more vital elements required for E/M (Evaluation and Management) level code selection services.
Expanded definition of time
The definition of time for many E/M services is no longer restricted to time spent for counseling, physicians can now use total time to select the level of service. Total time includes all physician or QHP time (both face-to-face and non-face-to-face) spent in care of the patient on the day of the encounter.
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Description of CPT code 99205
Providers report these codes for new patients being seen in the doctor’s office, a multispeciality group clinic, or other outpatient environment. All require a medically appropriate history and/or examination. Code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management. The most basic service is represented by 99202, which entails straightforward MDM. If time is used for code selection, 15 to 29 minutes of total time is spent on the day of encounter.
CPT code 99203 is reported for a visit requiring a low level of MDM or 30 to 44 minutes of total time;
CPT code 99204 is reported for a visit requiring a moderate level of MDM or 45 to 59 minutes of total time;
CPT code 99205 for a visit requiring a high level of MDM or 60 to 74 minutes of total time. The provider sees a new patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a high level of medical decision making and/or the provider spends 60–74 minutes of total time on the encounter on a single date.
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Coding guidelines for CPT code 99205
E/M visits are now to totally based on Time and MDM. If the coders calculate the time and MDM correctly, then as per the coding guidelines coder can choose the correct CPT code. Even for CPT code 99205 the same steps coders has to follow.
Time includes all activities (both face-to-face and non-face-to-face) related to the encounter performed by the physician or QHP on the date of the encounter. This includes activities such as reviewing external notes/tests/etc. not separately reported (billed), performing an examination, counseling and educating the patient/caregiver, and documenting in the medical record. Time spent performing activities normally completed by ancillary staff should not be included, and neither should travel time.
Time cannot be used to select the level of service for emergency department visits. The level of service is based on MDM. This does not differ from the previous guideline. However, the MDM levels have been modified to align with those for office visits.
MDM is the reflection of complexity in establishing a diagnosis, assessing the status of a condition and/or selecting a management option. The revised MDM table focuses on the cognitive work related to the diagnosis and assessment of a patient’s condition. Physicians should document the thought processes, including treatment options considered but not selected, that contribute to their diagnosis and treatment plan for the patient.