CPT Code 99201: New Patient Office or Other Outpatient Services, Level 1 - Chirotouch
January 26, 2024 by ChiroTouch Team Article Billing, Coding

This comprehensive guide to CPT code 99201 is designed to provide chiropractors with the essential information needed to accurately and efficiently use this code in their practice. Brought to you by ChiroTouch, the leading cloud-based EHR tailored for chiropractors, this resource addresses common questions and offers valuable insights into the proper application of CPT code 99201.

About CPT Code 99201: New Patient Office or Other Outpatient Services, Problem Focused, Minimal Severity

CPT code 99201 pertains to an office or other outpatient visit for the evaluation and management (E/M) of a new patient, categorized as Level 1. This code involves a patient encounter with minimal complexity and includes the following key components:

  • Brief history. Gathering limited information about the patient’s current health status.
  • Brief examination. Conducting a focused physical examination addressing the patient’s primary concerns.
  • Straightforward medical decision-making. Making simple decisions regarding the diagnosis and treatment plan based on the information obtained.

Chiropractors should familiarize themselves with the specifics of this code to ensure accurate usage in their billing and coding processes.

Category or Type of Service

CPT code 99201 falls under the Evaluation and Management (E/M) services category. As a Level 1 E/M service, it’s designated for new patients, indicating that the patient has not been seen by the provider or a provider in the same specialty within the same practice within the past three years.

Billing Interval

Typically billed per encounter, code 99201 is intended for brief visits, generally lasting less than 10 minutes. However, the complexity of the visit is more important than the time spent when choosing the code for the correct level. For encounters requiring more time or complexity, consider using higher-level E/M codes — 99202, 99203, 99204, or 99205.

When Should Chiropractors Use This Code?

Chiropractors should use CPT code 99201 for new patient office or other outpatient visits that meet the following criteria:

  • Limited history taking. Gathering brief information about the patient’s current health status.
  • Brief examination. Performing a focused physical examination addressing the primary concerns presented by the patient, typically less than 10 minutes, but the complexity of the visit should be the deciding factor on which code to choose.
  • Straightforward medical decision-making. Making simple decisions related to the diagnosis and treatment plan based on the limited information obtained.

When Should Chiropractors Not Use This Code?

Avoid using CPT code 99201 for comprehensive initial evaluations that require more in-depth history taking, examination, and complex decision-making, warranting higher-level codes, and for subsequent visits with established patients. Keep code 99201 for new patient encounters only.

Which Modifiers Can Be Used With CPT Code 99201?

The following modifiers are most commonly used with CPT code 99201:

  • Modifier 25. Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.
  • Modifier 59. A non-E/M procedure or service performed on the same day as another service but distinct and independent from it, even if they are typically bundled together by coding rules.
  • Modifier AT. Designating that a service or procedure was performed for an acute or chronic subluxation, specifically important when billing to Medicare.
  • Modifier GT. Used for telemedicine visits.

Always check payer-specific guidelines when using modifiers for accurate and compliant billing.

What Are the Billing Guidelines and Documentation Requirements Specific to This Code?

When using CPT code 99201, chiropractors must adhere to the following billing guidelines and documentation requirements:

  • Frequency of use. Verify billing frequency limits with each patient’s insurance carrier to ensure compliance with the specific CPT code.
  • New patient status. This code is exclusive to new patients, and an established patient-provider relationship must not be in place.
  • Face-to-face encounter. The provider must physically see the patient, either in person or via telehealth.

Providers must document a clinical need, provide care addressing that need, and note decision-making regarding the treatment plan during the visit. If additional chiropractic services are rendered on the same day, code 99201 should be billed separately with appropriate modifiers.

What Are Common Mistakes Made Specific to CPT Code 99201?

Avoid these common mistakes when using CPT code 99201:

  • Excessive use. Limit 99201 to new patient encounters with minimal complexity.
  • Using it for established patients. Use other codes for patients you see regularly.
  • Relying on time alone. Complexity is your best guide for using 99201.
  • Treating it as a “catch-all” code. Use 99201 for visits with limited history, brief examination, and straightforward decision-making.
  • Insufficient documentation. Provide specific details reflecting the level of complexity encountered during the visit.
  • Inconsistent documentation. Make sure there’s consistency between documented complexity and time spent.

What Are Potential Audit Triggers Specific to This CPT Code?

Audit triggers specific to CPT code 99201 may include:

  • Inconsistent use of time. Billing 99201 uniformly for all new patient visits regardless of complexity.
  • Lack of supporting documentation. Vague or incomplete documentation can cast doubt on the justification for using 99201.
  • Inadequate medical decision-making complexity. The documented decision-making process should fit the expected complexity for this code.
  • Including services bundled into 99201. Check coding guidelines to prevent billing for bundled services.
  • Frequent use for chronic conditions. Provide evidence of ongoing management for chronic cases.

Sticking to coding guidelines and payer policies will help chiropractors avoid potential audit triggers.

What Can I Do to Improve the Accuracy and Efficiency of My Practice’s Billing and Coding Processes?

Chiropractors can enhance the accuracy and efficiency of their billing and coding processes by:

  • Performing regular audits. Regularly review billing and coding practices to find and fix potential issues.
  • Staying informed. Keep up to date with changes in billing and coding regulations.
  • Utilizing technology.  Implement cloud-based EHR and practice management software designed for chiropractors, such as ChiroTouch.

By following these steps, chiropractors can ensure compliant and efficient billing and coding practices within their practice.

To learn more about choosing the correct code level for new patient office visits, read CPT Codes 99201-99205: New Patient Office or Other Outpatient Services.

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