CPT CODE 99213: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Level 3
In this quick reference guide to CPT code 99213, 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.
About CPT Code 99213: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Level 3
CPT code 99213 pertains to an established patient office or other outpatient visit for evaluation and management (E/M) services. Use of this code requires at least two of three key components:
- Expanded problem-focused history. Any visit coded 99213 should involve gathering detailed information about the patient’s current health concerns and relevant past medical history.
- Expanded problem-focused examination. Conduct a thorough physical examination focused on the identified problems.
- Moderate medical decision-making. The visit should involve making decisions about diagnosis, treatment plans, and prognosis based on the collected information.
Chiropractors can use this code to accurately bill for visits with established patients of moderate complexity.
Category or Type of Service
CPT code 99213 falls under the category of Evaluation and Management (E/M) services. It is designated for established patients who have been seen by a provider in the same specialty, at the same practice, within the past three years.
A patient who has seen multiple providers in the same practice can be billed under this code as long as the providers offered the same specialty.
This code is typically billed per encounter, and it’s suitable for visits of moderate complexity, typically ranging from 30-39 minutes. However, while time spent is a factor, the main criterion for choosing code 99213 should be the complexity of the visit, not the duration.
Remember that the last digit of the code corresponds to the complexity. Look at the criteria for using the code if you’re not sure, and compare to past billings where this code was cleared by the insurer.
When Should Chiropractors Use This Code?
Chiropractors should use CPT code 99213 when they perform a detailed examination and management of a patient’s health of moderate complexity. This code is appropriate for encounters that involve a thorough assessment, decision-making, and coordination of care.
Common scenarios where this code would be appropriate include encounters with patients who have complex health issues or cases where you or your staff spend a significant amount of time reviewing medical records and coordinating care with other healthcare providers.
When choosing among levels in the 99211-99215 series, prioritize medical decision-making (MDM) over length of visit as the primary factor in determining the correct code level. Time is a secondary but still important consideration.
|New patient office visit, level 1
|New patient office visit, level 2
|New patient office visit, level 3
|Established patient office visit, level 4
|Established patient office visit, level 5
|50 or more minutes
When Should Chiropractors Not Use This Code?
Chiropractors shouldn’t use code 99213 for:
- Comprehensive initial evaluations
- Chiropractic manipulative treatment (CMT) sessions
- Extensive discussions or counseling
These should be billed under other codes. Consider reviewing the patient history.
Which Modifiers Can Be Used With CPT Code 99213?
Chiropractors can use the following modifier codes with CPT code 99213:
- Modifier 25. Indicates a separate and distinct E/M service performed on the same day as another procedure or service.
- Modifier 59. Signifies that a procedure or service was distinct or independent from other services performed on the same day.
- Modifier AT. Used to indicate a service or procedure performed for an acute or chronic subluxation. This modifier is mandatory for 99213 encounters billed to Medicare.
- Modifier 95. Signifies that the E/M service was delivered via interactive audio-video telecommunications technology.
- Modifier GT. Also used for telehealth services. This is more common in cases where insurance providers haven’t universally accepted modifier 95.
Always review payer-specific guidelines when using modifiers. It will help with accuracy and limit billing issues later on.
What Are the Billing Guidelines and Documentation Requirements Specific to This Code?
To ensure accurate billing, adhere to the following guidelines and documentation requirements for code 99213:
- Check the patient’s insurance plan for billing code frequency limits.
- Confirm there’s an existing patient-provider relationship.
- Remember that a provider has to physically see the patient, either in person or via telehealth.
- Conduct evaluation and management during the visit to address clinical needs, and note decision-making regarding the treatment plan.
If additional chiropractic services are provided on the same day, you may need to bill 99213 separately with modifier 59. Check that there’s clear, legible, and specific documentation signed and dated by the chiropractor.
Common Mistakes Made Specific to CPT Code 99213
These common mistakes most commonly occur when using CPT code 99213:
- Excessive use. Reserve code 99213 for established patient visits with moderate complexity.
- Using it for new patients. Keep this code strictly for established patients.
- Relying on time alone. Complexity should be your main reason for using this code, with time spent a secondary consideration.
- Treating it as a “catch-all” code. Use 99213 for visits with focused history taking, moderate examination, and straightforward decision-making.
- Insufficient or inconsistent documentation. Use specific terminology reflecting the level of complexity. Be sure the documentation fits the moderate level of E/M services provided.
- Misunderstanding payer policies. Review each payer’s policies for specific requirements or limitations.
- Ignoring modifiers. Use appropriate modifiers like 25 or 59 when warranted and documented.
- Upcoding or downcoding. Choose the code accurately reflecting the service provided.
- Billing for services not included. Avoid billing for bundled services or administrative tasks.
Thorough and detailed documentation will be your key to accurate billing and minimizing claim denials.
Potential Audit Triggers Specific to This CPT Code
Be aware of potential audit triggers for CPT code 99213:
- Inconsistent use of time. Document the actual level of E/M elements, not just time spent.
- Lack of supporting documentation. Provide clear evidence supporting the moderate level of complexity.
- Lack of differentiation between established and new patients. New patient E/M visits should be coded under 99201-99205, New Patient Office or Other Outpatient Services.
- Including services bundled into 99213. Ensure compliance with coding guidelines and payer policies.
- Frequent use for chronic conditions. Document adjustments to demonstrate ongoing management.
- Telehealth coding discrepancies. Use appropriate modifiers for any telehealth visits.
- Modifier misuse. Clearly support the use of modifiers to avoid confusion.
- Unusual billing patterns. Sudden spikes may attract attention; ensure compliance with guidelines and policies.
Improve the Accuracy and Efficiency of Your Practice’s Billing and Coding Processes
Chiropractors can enhance billing and coding processes by:
- Performing comprehensive audits.
- Staying updated on changes to billing and coding regulations.
- Using ChiroTouch’s cloud-based EHR and practice management software designed for chiropractors.
By following these steps, chiropractors can ensure the accuracy and efficiency of their billing and coding practices, reducing the risk of claim denials and enhancing overall practice management.
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