Established Patient Office Visit (99211 - 99215): Coverage and Documentation Requirements

Published 02/07/2018

This Comparative Billing Report (CBR) focuses on physicians who submit claims for Established Patient Office Visit code family (CPT codes 99211 – 99215). CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

For your personalized Established Patient Office Visit (CPT codes 99211–99215) eCBR results Logon to eServices.

Established Patient Office Visit (CPT codes 99211–99215): Coverage and Documentation Requirements

CPT Code
Level of Severity
Time Spent
Key Components
99211
Problem(s) are minimal.
Typically 5 minutes  spent to perform or supervise.
None.
99212
Problem(s) are self-limited or minor.
Typically 15 minutes  spent face-to-face with the patient and/or family.
 
Requires 2 of these 3 key components:
- A problem focused history
- A problem focused examination and
- Straightforward medical decision making
99213
Problem(s) are of low to moderate severity.
Typically 15 minutes spent face-to-face with the patient and/or family.
 
Requires 2 of these 3 key components:
- An expanded problem focused history
- An expanded problem focused examination and
- Medical decision making of low complexity
99214
Presenting problem(s) are of moderate to high severity.
Typically 25 minutes spent face-to-face with the patient and/or family.
Requires 2 of these 3 key components:
- A detailed history
- A detailed examination and
- Medical decision making of moderate complexity
99215
Presenting problem(s) are of moderate to high severity.
 
Complex medical decision making involves at least 2 of the following:
- extensive management options
- extensive amount of data reviewed
- high risk of complications and/or morbidity or mortality
Typically 40 minutes are spent face-to-face with the patient and/or family.
Requires 2 of these 3 key components: 
- A comprehensive history
- A comprehensive examination and
- Medical decision making of high complexity
 

Education Resources:
The Provider Outreach and Education (POE) team has published an educational video session to address the issues pertinent to this CBR. Your practice is being advised to view this video.

Methods
The metrics reviewed in this CBR are the proportion of billing for each HCPCS code in the grouping with comparisons done to peers with the same specialty in the state and the jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. For the purpose of this CBR, 'peer group' is defined as other providers in Jurisdiction M (JM) who have the same specialty. The analysis shows the portions of your Established Patient Office Visit family of codes (CPT codes 99211-99215) claims at each level compared to your peers in JM.

Example of eCBR Results from eServices 

eCBR Lookup

Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.


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