CPT Code 99205: New Patient Office or Other Outpatient Services, Level 5 - Chirotouch
March 25, 2023 by ChiroTouch Team Article Coding

In this quick reference guide to CPT code 99205, we answer frequently asked questions from our community of chiropractors. Follow us for other articles in our ongoing series, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors. 

NOTE: CPT codes and guidelines can be revised over time. To avoid billing issues, be sure to stay current with annual coding updates and changes to payer guidelines.

About CPT Code 99205: New Patient Office or Other Outpatient Services, Comprehensive, Moderate to High Severity, Level 5

CPT code 99205 pertains to an initial comprehensive office or other outpatient visit for evaluation and management services with three key components:

  • Comprehensive history taking: Extensive information regarding the patient’s current health concerns, past medical history, family history, social history, and review of systems.
  • Comprehensive examination: A thorough physical examination addressing all pertinent organ systems and presenting problems.
  • High-complexity medical decision-making: Intricate decisions concerning diagnosis, treatment plans, and prognosis based on the comprehensive history, examination, and medical data.

Here’s what chiropractors need to know about using CPT code 99205.

Category or Type of Service

CPT code 99205 falls under the category of Evaluation and Management (E/M) services. It is designated as a level 5 E/M service, representing the highest complexity level for new patient encounters with a specific chiropractor.

Billing Interval

This code is typically billed per encounter. Code 99205 is for visits of high complexity, generally lasting from 60 to 74 minutes. While medical decision-making complexity is the primary factor for determining the level of E/M services, time is also important.

You can choose to code based on either:

  • Medical decision-making. The complexity of the diagnoses, data reviewed, and treatment/management options considered.
  • Total time. The total time spent with the patient on the date of service, including face-to-face and non-face-to-face time (like reviewing records or discussions with other practitioners).

Note: If using time as the deciding factor, documentation must clearly support the time spent on the encounter, and complexity of medical decision-making must be high.

When Should Chiropractors Use This Code?

Chiropractors should use CPT code 99205 for highly complex initial evaluations of new patients. This includes situations where:

  • An extensive and thorough history-taking is necessary to fully understand the patient’s complex medical background and the context of their current health issues.
  • A comprehensive physical examination is required to assess the patient’s current health status in detail, including a thorough evaluation of multiple body systems and complex anatomical regions relevant to the patient’s presenting problems.
  • High complexity medical decision-making is involved in determining the diagnosis, treatment plan, and prognosis based on the comprehensive assessment. This may include analyzing extensive data, considering multiple complex diagnoses, and weighing potential risks and benefits of various treatment options.
  • The total time typically spent on the encounter, including face-to-face and non-face-to-face time, falls within the range of 60-74 minutes. However, it is important to note that when deciding between different E/M codes, the complexity of care provided (as determined by the level of medical decision-making) should be considered first, and time spent with the patient second.

When Should Chiropractors Not Use This Code?

Chiropractors should avoid using CPT code 99205 for:

  • Established patient visits. This code is specifically for new patients for a specific provider.
  • Routine follow-up visits. Lower-level codes are more appropriate for less complex follow-up appointments.
  • Less complex new patient encounters. If the encounter doesn’t meet the criteria for comprehensive history, examination, and medical decision-making, use a lower-level code.

Checking your encounters against these criteria is a useful tool for preventing miscoding.

Which Modifiers Can Be Used With CPT Code 99205?

Modifiers can enhance accurate billing for CPT code 99205:

  • Modifier 25. Indicates a separate and distinct E/M service provided on the same day as another procedure or service.
  • Modifier 59. Indicates a separate identifiable procedure performed during the same encounter.
  • Modifier AT. Signifies that the service or procedure was performed for an acute or chronic subluxation. This modifier is often required for Medicare billing and may be required by other payers to indicate the specific nature of the chiropractic service.
  • Modifier 95 or GT. Used for telehealth services.

Billing Guidelines and Documentation Requirements

Adhering to specific billing guidelines and documentation requirements is essential. Be sure to:

  • Check with the patient’s insurance carrier to determine if there are any specific frequency limits for this code. Some payers may have restrictions on how often certain services can be billed.
  • Ensure an established patient-provider relationship is in place for new patient encounters.
  • Provide face-to-face encounters either in person or via telehealth.
  • Document a comprehensive history, examination, and medical decision-making process.
  • Bill additional chiropractic services separately if provided on the same day.

Common Mistakes Made Specific to CPT Code 99205

Avoid these common mistakes when using CPT code 99205:

  • Overuse of the code for services not meeting the criteria.
  • Failure to distinguish between new patients and established patient encounters.
  • Neglecting to document the comprehensive nature of the visit.
  • Misuse or omission of modifiers.

Potential Audit Triggers

Be aware of potential audit triggers, including:

  • Inconsistent use of time and complexity when applying the code. While both are important, the complexity of the visit trumps the time spent.
  • Insufficient supporting documentation. Clear and detailed documentation helps limit audit risk.
  • Inadequate complexity of medical decision-making. Before billing 99205, check to see how the complexity measures up to past billing.
  • Incorrect billing patterns or modifier usage. Remember, audits are about overall patterns, not just individual encounters.

Improving Billing and Coding Processes

To enhance accuracy and efficiency in billing and coding:

  • Conduct regular audits of billing and coding practices.
  • Stay updated on coding regulations and changes.
  • Utilize specialized EHR and practice management software tailored for chiropractors.

Understanding and applying CPT code 99205 correctly can streamline billing processes and ensure appropriate reimbursement for chiropractic services rendered.

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