Medical billing is a highly complex process. It is not easy for many doctors, business professionals, and learners. CPT codes are crucial to billing and getting reimbursed precisely. There are so many codes, but one of the most common ones is CPT code 99213. However, these codes play a vital role in everyday medical practice. It means that when you pay for a particular service, only healthcare providers are paid appropriately.
Without understanding this CPT code, numerous errors in billing are going to occur. It might mean delays in your payments and, at worst, cause a denial of your claim. Therefore, in this blog, we will find information regarding the 99213 CPT. You will learn when and how you should apply these billing guidelines in the right way. We want it to be as easy to understand as possible. Whether you are coming fresh to medical billing or you want to remember what you have forgotten, this guide is for you. Let’s take a look at CPT code 99213 together.
What are CPT Codes?
CPT code refers to the Current Procedural Terminology (CPT) Disease. Healthcare providers use these codes to describe medical services and procedures. The American Medical Association oversees the CPT codes to make sure the medical fraternity uses the exact wording. It generalizes what doctors do to ensure that everyone, from doctors and insurance companies to the patient, knows what the services are. For instance, if a doctor gives someone a routine checkup, they will forward their bill to the patient using a specific CPT code for that visit. CPT codes are very important to accurate billing and payment. If they didn’t exist, it would be confusing sometimes and would take more time to be paid. Understanding CPT codes makes our work get the billing process simple.
Why are CPT Codes Important?
Telemedicine app development company provide CPT codes to follow standardized language that healthcare providers, patients, and payers (such as insurance companies) can use. It will ensure clear communication. CPT codes are employed for billing purposes. Proper coding will allow reimbursement for services provided. It also helps in data collection in healthcare services, which are the basis of any policy and research.
Types of CPT Codes
There are three types of CPT codes.
- Category I: CPT codes are utilized in procedures or services that are performed often.
- Category II: Supplementary tracking codes, which help for performance management.
- Category III: Emerging technology, services, and procedure codes.
E/M Codes Overview
Physician-patient encounter services fall under the scope of group Evaluation and Management Services. Code 99213 is an example of this type of code. The “CPT” code is merely a short term for the Current Procedural Terminology code. CPT codes describe procedures, both surgical and non-invasive. E/M services classifications take into account variables like the difficulty in dealing with a patient’s problem, history obtained, examination, and decision-making.
Moreover, evaluation and management codes promote uniformity in billing across all healthcare settings. Such a process ensures that healthcare providers are paid for their time and expertise resources during each encounter with the patient. With the use of E/M codes, healthcare providers can ensure consistency and avoid errors when developing a billing process, which would favour both the providers and the patients.
Levels of E/M Codes
E/M codes have multiple levels that depend on the complexity of the visit and the time taken. For established patients seen in the office or other outpatient departments, the range begins at 99211 and moves to 99215.
99211: Low-level issues; low-level visits.
99212: Problem-focused.
99213: Expanded problem-focused.
99214: High level of documentation.
99215: Comprehensive.
When to Use CPT Code 99213
1. Appropriate Situations
CPT code 99213 is appropriate when the patient has a visit that includes:
- Minor to Moderately Serious Problems: Stable or improving stable needs to be followed.
- Chronic Condition Follow-ups: Follow-ups for conditions such as hypertension, diabetes, or asthma.
- Medication Management: Titration of doses or side effects of medications.
- Reviewing Test Results: Follow-up on lab tests or imaging that need interpretation.
- Addressing New Symptoms: Minimal new symptoms that may not necessitate significant workup.
2. Examples of Visits
- Hypertension Management: A patient whose blood pressure is controlled comes in for a follow-up
- Diabetes Follow-up: A patient whose blood glucose is being monitored comes in with their blood glucose logs and discusses them with the physician. The physician adjusts their insulin based on the results.
- Asthma Monitoring: A patient with asthma reports an occasional wheeze, and the physician checks her inhaler technique.
- Medication Side Effects: If a patient develops minimal side effects from a new medication, the physician adjusts the medication.
3. Inappropriate Use
Do not use CPT Medical code 99213 for:
- Minimum Visits: Use 99211 instead.
- Complex Visits: If the visit involves critical examination and significant complexity decision-making, use 99214 or 99215.
- New Patients: For new patients, use codes 99201-99205.
Decomposing the Elements of CPT Code 99213
To properly use CPT code 99213, you must be familiar with its three components: History, Examination, and Medical Decision Making. Of these three elements, at least two must be eligible to use this code.
1. History
Extended Problem-Focused History
This type of history includes:
- Chief Complaint (CC): The main reason for the patient’s visit.
- History of Present Illness (HPI): A brief description of the symptom or issue (1-3 words).
- Review of Systems (ROS): A problem-specific review directly related to the presenting issue.
- Past, Family, and Social History (PFSH): Included only if relevant to the problem.
Example:
- CC: “Follow-up on hypertension.”
- HPI: Occasional headaches at home; blood pressure recorded as 130/85.
- ROS: Afebrile, no chest pain, dizziness, or shortness of breath reported.
2. Oriented History
Enlarged Problem-Oriented History
This type of history includes a detailed evaluation of the following medical billing and coding:
- Focused History: Assessment of the affected area or organ system, along with related systems (covering at least 2-7 systems or areas).
- Vital Signs: These include blood pressure, heart rate, and respiratory rate.
- Cardiovascular Exam: Normal heart sounds; no murmurs detected.
- Respiratory Exam: Lungs clear upon auscultation.
3. Medical Decision-Making
Low Complexity
This level of medical decision-making involves:
- Number of Diagnoses or Management Options: Few, typically one stable chronic condition.
- Quantity and Complexity of Data Assessed: Limited data, such as evaluating basic lab studies.
- Risk of Complications: Low risk for the patient’s condition or treatment plan.
Example:
- Adjusting an antihypertensive dosage.
- Ordering routine laboratory tests.
CPT 99213 Billing Guidance
Accurate billing ensures that healthcare practitioners adhere to the standard requirements, thus availing the proper reimbursement. Some of the key billing guidance are as follows:
Documentation Requirements
It is essential to ensure that the level of service matches the documentation. Medical billing code 99213 requires two of the three major components to be documented. Providers must record all history, examination, and medical decision-making. Time is not the primary factor unless counselling or care coordination takes up more than half the encounter time.
Modifiers
Modifiers are two-digit codes added to a CPT code to give additional detail. Modifier 25 is used for a significant, separate E/M service performed on the same day as another procedure. For example, adding Modifier 25 would be necessary if a patient visits for wart removal but also needs blood pressure management. Modifier 59 identifies services as distinct and separate when performed on the same day.
Avoiding Common Pitfalls
Upcoding, or billing for a higher level of service than performed, is fraudulent and punishable. Undercoding can lead to revenue loss and missed opportunities. Cloning documentation or copying details from prior visits without updates may result in inaccurate records. Accurate documentation improves patient care and ensures proper billing.
Time-Based Coding
Time only determines the 99213 CPT code if the primary focus is on counselling or care coordination. If counselling accounts for more than half of the appointment, it must be documented. For instance, if a 20-minute visit includes 12 minutes of counselling on lifestyle changes, documentation should reflect this, supporting the appropriate billing code.
Medical Necessity
Medical necessity is key in selecting the proper level of service. The care provided must be reasonable and necessary for the diagnosis or treatment of the patient’s condition. Even for higher levels of service, adequate documentation of necessity is required. Avoid providing or billing for medical services that are not justified by the patient’s condition.
Practice Tips in Accurate Documentation
Proper documentation is vital for accurate billing and better patient care. Clearly record the chief complaint, relevant findings, and diagnoses in a specific and descriptive manner. Include treatments, patient education, and both positive and negative examination results. Use clear, plain language to ensure readability for all.
Timeliness
Documentation should be completed promptly after the encounter to maintain accuracy. Regularly update patient records to reflect current information, including medications and allergies. Timely documentation ensures comprehensive care and reduces the risk of errors in billing and treatment records.
Staying Current on Changes
Healthcare laws and CPT codes change frequently, requiring professionals to stay updated. Use resources like the American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and professional associations for the latest information. Attend workshops, webinars, and courses to remain informed about billing and coding standards.
Keeping Current
Regular training ensures billing staff stays informed about updates in coding guidelines. Review internal policies periodically to align them with industry standards. Ensure that electronic health record (EHR) systems are updated with the latest coding features to streamline documentation and billing processes.
Knowledge of Compliance and Audits
Maintaining coding compliance helps avoid losses and withstand audits. Regularly train staff on compliance requirements and audit protocols. Proper documentation and adherence to current guidelines reduce risks and improve the reliability of the billing process, ensuring accuracy and regulatory compliance.
Need for Compliance
Legal Protection: This is because of the law and the reduction in the risk due to the law.
Financial Integrity: Correct reimbursement without fines being imposed.
Reputation Management: A maintained relationship with the trust of patients and payers.
Documentation Audit: Fields to be analyzed regularly to update the codes for the records.
Internal Controls: Put controls and checks in billing.
External Audits: Any external audits that prove ways of improvement.
Technology and CPT Code 99213
Technology can help with accurate coding and documentation with medical billing code 99213.
Electronic Health Records (EHR)
- Templates: Utilize templates specific to EHR and CPT code 99213; therefore, all elements are met.
- Alerts: Set up to alert missing documentation components.
- Efficiency: Such a process streamlines the time lost on documentation.
Coding Software
- Support: Provides suggestions for applicable codes based on documentation.
- Updates: Includes any new coding updates automatically.
- Error Reduction: Helps minimize the chances of coding mistakes through internal checks.
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Conclusion
Understanding code 99213 is essential when it comes to correct medical billing and coding services. Knowledge of when and how to apply the correct code will empower the clinician to get the clinician up to the codes, correct reimbursement, and optimal care for the patients. Do not forget to note down your cases appropriately and be conscious of the changes that are in coding; also, learn how to use technology to aid you.
Frequently Asked Questions
Q1. Would it be okay if I used CPT code 99213 for telemedicine?
Sure, I can use this for an established patient telemedicine visit. It satisfies all the necessary components. In addition, attach the relevant telehealth modifiers. Remember to research and consider the payer’s specific stipulations before proceeding.
Q2. What if the visit includes both a procedure and an E/M service?
If the procedure and the E/M service are significant and separately identifiable, you can report for both. Use modifier 25 with the E/M code.
Q3. How does time factor into choosing CPT code 99213?
Time is not as important a determinant unless counselling or coordination of care is the primary portion of the visit. If counselling is more than 50% of the visit, time can be the determinant of code level.
Q4. Is it acceptable to use CPT code 99213 for new patients?
No. CPT code 99213 is only for established patients. Utilize codes 99201-99205 for new patient visits.
Q5. What documentation is needed if counselling is the predominant portion of the visit?
Note the total visit time, counselling time, and a summary of the general topics of counselling.
