CPT CODE 99212: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Level 2
This quick reference guide to CPT code 99212 answers frequently asked questions from our community of chiropractors. You can see the complete library of CPT codes here, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors.
About CPT Code 99212: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Level 2
CPT code 99212 refers to an established patient office or other outpatient visit for evaluation and management (E/M) services with two of three key components:
- Problem-focused history: This involves gathering information about the patient’s current health concerns and any relevant past medical history.
- Problem-focused examination: This involves performing a physical examination focused on the identified problems.
- Straightforward medical decision-making: This involves making decisions about the diagnosis, treatment plan, and prognosis based on the gathered information.
Here’s what chiropractors need to know about using CPT code 99212.
Category or Type of Service
CPT code 99212 falls under the category of Evaluation and Management (E/M) services. This code is a level 2 E/M service, as indicated by the last digit of the code. It is designated for established patients, meaning the patient has been seen by the provider or a provider in the same specialty within the same practice within the past three years.
This code is typically billed per encounter. Code 99212 is for visits of moderate complexity, typically from 10-19 minutes. For lower-complexity encounters, use code 99211. For higher-complexity encounters, use code 99213, 99214, or 99215.
When Should Chiropractors Use This Code?
Chiropractors should use CPT code 99212 for established patient office or other outpatient visits that meet the following criteria:
Moderate history taking: Gathering information about the patient’s current health concerns and relevant past medical history with a focus on one or two key problems.
Moderate examination: Focused physical examination on the identified problems, potentially including specific chiropractic tests or maneuvers.
Straightforward medical decision-making: Making decisions about the diagnosis, treatment plan, and prognosis based on the gathered information. This may involve ordering tests, referring the patient to another healthcare professional, or adjusting the chiropractic care plan.
When assessing whether to use 99212 or a higher- or lower-level code, consider both the time involved and the complexity of the care provided. Complexity is the more important factor.
When Should Chiropractors Not Use This Code?
Chiropractors should not use CPT code 99212 for:
- Comprehensive initial evaluations: These require more in-depth history taking, examination, and complex decision-making, and should be billed with a higher-level code.
- Chiropractic manipulative treatment (CMT) sessions: CMT is a separate service from E/M and should be billed with the appropriate CMT code unless the E/M service is significantly distinct and separately identifiable.
- Extensive discussions or counseling: If the visit primarily involves lengthy discussions about lifestyle modifications, pain management strategies, or chronic disease management, consider a code appropriate for counseling and cognitive services.
Which Modifiers Can Be Used With CPT Code 99212?
The following modifier codes are often used with CPT code 99212:
- Modifier 25: This modifier indicates that a separate and distinct E/M service was performed on the same day as another procedure or service (e.g., an injection or minor surgery). The additional E/M service must warrant a separate encounter and document the history, examination, and medical decision-making related to the specific issue addressed.
- Modifier 59: Indicates that a procedure or service was distinct or independent from other services performed on the same day.
- Modifier AT: Used to signify that a service or procedure was performed for an acute or chronic subluxation. This modifier must be used for 99212 encounters billed to Medicare.
- Modifier 95: This modifier signifies that the E/M service was delivered via interactive audio-video telecommunications technology.
- Modifier GT: This is also used for telehealth services but is more common in cases where insurance providers have not yet transitioned to the more universally accepted modifier 95.
Always review and comply with payer-specific guidelines when using modifiers to ensure accurate and compliant billing.
What Are the Billing Guidelines and Documentation Requirements Specific to This Code?
The following billing guidelines and documentation requirements apply to code 99212:
- Frequency of use: The frequency with which certain billing codes can be used depends on the client’s insurance plan. Verify with each patient’s insurance carrier to confirm specifics around billing frequency limits for this CPT and similar codes prior to submitting claims.
- Established patient: An established patient-provider relationship must already be in place, as this code does not apply to new patients.
- Face-to-face encounter: The provider must actually see the patient, either in person or by telehealth. Over-the-phone services do not qualify.
- Care provided: Some evaluation and management of the established patient must occur during the visit. Simply documenting a patient’s medical history alone is not enough. Providers need to identify a clinical need, provide care to address the need, and note decision-making regarding the patient’s treatment plan.
- Separate billing: If additional chiropractic services are provided on the same day, 99212 must be billed as a separate charge using modifier 59. The documentation must be clear, legible, and specific and must demonstrate the degree of complexity. It must be signed and dated by the chiropractor who performed the chiropractic service.
What are Examples of ICD-10-CM Codes Often Used With This Code?
The following ICD-10-CM codes are often used with CPT code 99212:
- Z00.12: Encounter for routine check-up or examination
- R10.0: Follow-up examination after other procedures
- R15.2: Follow-up examination after medication use
These are just a few examples, and it is important to select the most accurate and specific diagnosis code based on the patient’s condition and the clinical documentation.
What Are Common Mistakes Made Specific to CPT code 99212?
Some common mistakes made with this code include:
- Excessive use: Code 99212 is not meant for every service your practice provides. Only use it for established patient E/M visits with minimal problems and minimal chiropractor involvement.
- Using it for a new patient visit. This code is to be used for established patients only.
- Relying on time as the sole factor: The complexity of the E/M elements (history, exam, decision-making) should be the primary determinant. Don’t use 99212 for brief consultations or simple follow-ups that lack moderate complexity.
- Treating it as a “catch-all” code: This code is not meant for every patient encounter. Reserve it for visits with focused history taking, moderate examination, and straightforward decision-making related to one or two key problems.
- Insufficient documentation: Use specific terminology and details that accurately reflect the level of complexity.
- Inconsistent documentation: Ensure your documentation consistently reflects the moderate level of E/M services provided. Avoid inconsistencies between time spent and documented complexity.
- Misunderstanding payer policies: Each payer may have specific requirements or limitations for using 99212. Review your payer’s policies to ensure you’re meeting their expectations.
- Ignoring modifiers: Don’t miss opportunities to use appropriate modifiers like 25 (significant E/M service) or 59 (distinct procedure) when warranted and documented.
- Upcoding or downcoding: Choose the code that accurately reflects the level of service provided.
- Billing for services not included: Don’t bill for phone calls, administrative tasks, or services bundled into other codes.
- Billing for bundled services: Don’t bill for services already included in 99212, like simple injections or medication refills.
- Overlooking modifiers for telehealth services: If you provide E/M services via telehealth, remember to use the appropriate modifier (e.g., 95 or GT) to ensure accurate billing.
To ensure accurate billing and minimize claim denials, it is crucial to provide thorough and detailed documentation that supports the medical necessity of the service rendered.
What Are Potential Audit Triggers Specific to This CPT Code?
Some potential audit triggers specific to CPT code 99212 include:
- Inconsistent use of time: Billing 99212 consistently for all established patient visits, regardless of complexity, raises suspicion. Auditors may scrutinize cases where the documented time aligns perfectly with the 10-19 minute range for the code. Ensure your documentation reflects the actual level of E/M elements, not just time spent.
- Lack of supporting documentation: Vague or incomplete documentation of the history, examination, and medical decision-making (MDM) process can raise doubts about the justification for using 99212. Auditors need clear evidence to support the moderate level of complexity. Provide detailed descriptions of the key problems addressed, data reviewed, and rationale for decisions made.
- Inadequate MDM complexity: If the documented MDM is superficial or lacks complexity (e.g., data reviewed, decisions made), it might not support a 99212 code. Auditors expect a higher level of clinical reasoning for this code. Demonstrate the moderate complexity by describing the challenges faced, alternative considerations evaluated, and the reasoning behind your chosen course of action.
- Including services already bundled into 99212: Review your coding guidelines and payer policies to ensure you’re not billing for services already covered by the code.
- Frequent use for chronic conditions: While 99212 can be appropriate for managing stable chronic conditions, excessive use without evidence of monitoring or adjustments could raise suspicion. Auditors expect proactive management for chronic cases. Document adjustments to the treatment plan, medication changes, or other interventions undertaken during each visit to demonstrate ongoing management.
- Telehealth coding discrepancies: If you provide E/M services via telehealth, ensure you’re using the appropriate modifier (e.g., 95 or GT) and documenting the specific telehealth modality and its impact on the encounter. Discrepancies between documentation and billing for telehealth services can trigger audits.
- Modifier misuse: Improper use of modifiers like 25 (significant E/M service) or 59 (distinct procedure) without proper justification can raise questions. Ensure your documentation clearly supports the use of any modifiers to avoid confusion during audits.
- Unusual billing patterns: Sudden spikes in the use of 99212, particularly for new patients or specific diagnoses, can attract attention. Auditors may investigate unusual billing patterns to ensure compliance with coding guidelines and payer policies.
What Can I Do to Improve the Accuracy and Efficiency of My Practice’s Billing and Coding Processes?
Chiropractors can take some immediate steps to improve the accuracy and efficiency of their practice’s billing and coding such as:
- Performing comprehensive and frequent audits of billing and coding practices
- Staying up-to-date on changes to billing and coding regulations
- Using cloud-based EHR and practice management software created to meet the needs of chiropractors
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