CPT Codes 99201-99205: New Patient Office or Other Outpatient Services

This quick reference guide to CPT codes 99201-99205 answers frequently asked questions from our community of chiropractors, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors. 

About CPT Codes 99201-99205: New Patient Office or Other Outpatient Services

CPT codes 99201-99205 represent the evaluation and management services provided by chiropractors during patient encounters. These codes differ in the complexity of the E/M services provided.

Category or Type of Service

CPT codes 99201-99205 fall under the category of Evaluation and Management (E/M) services. These codes specifically pertain to office visits and evaluations conducted by chiropractors to assess and manage their patients’ healthcare needs.

What Are the Billing Intervals for CPT Codes 99201-99205?

CPT codes 99201-99205 are typically billed per encounter. Each patient visit or office encounter warrants the selection of the appropriate E/M code based on the complexity of the visit.

How Do I Determine Which CPT Code (99201-99205) to Use for a Patient Encounter?

Determining the correct E/M code to use for a patient encounter involves assessing the complexity of the visit based on three key components: history, examination, and medical decision-making. Each component has various elements that contribute to the overall level of complexity.

Let’s break it down:

History

This component involves gathering information about the patient’s chief complaint, present illness, past medical history, family history, and social history. The levels of history documentation are as follows:

• Problem-focused. Brief history related to the presenting problem.
• Expanded problem-focused. Brief history plus limited additional history related to the presenting problem.
• Detailed. Extended history that addresses the chief complaint and includes an extended review of systems.
• Comprehensive. Complete history covering all elements of the chief complaint, plus a complete review of systems and the patient’s past, family, and social history.

Examination

This component includes the physical examination performed by the chiropractor. The levels of examination documentation are as follows:

• Problem-focused. Examination limited to the affected body area or organ system.
• Expanded problem-focused. Limited examination of the affected body area or organ system, plus other relevant systems.
• Detailed. Extended examination of the affected body area or organ system and other relevant systems.
• Comprehensive. General multi-system examination or complete examination of a single organ system.

Medical Decision-Making

This component involves the complexity of establishing a diagnosis and determining a management plan. The levels of medical decision-making are based on the following elements:

• Number of diagnoses or management options considered.
• Amount and/or complexity of data reviewed.
• Risk of complications and/or morbidity or mortality.

By carefully evaluating each of these components and their corresponding elements, chiropractors can determine the appropriate E/M code that accurately reflects the complexity of the patient encounter.

Proper documentation is crucial when using E/M codes. Chiropractors should ensure that their notes clearly and accurately reflect the level of complexity and support the code chosen for billing purposes. Additionally, compliance with documentation guidelines set forth by Medicare and other third-party payers is essential to avoid potential audits or denials.

When Should Chiropractors Use These Codes?

Chiropractors should use codes 99201-99205 when conducting office visits or evaluations for new patients. The level of complexity associated with the patient encounter should dictate the choice of code. It is important to accurately document the history, examination, and medical decision-making to support the selected code.

When Should Chiropractors Not Use Codes 99201-99205 ?

Chiropractors should not use these codes for established patient encounters. Established patients are those who have previously received treatment or evaluation from the chiropractor. For established patients, different E/M codes, such as codes 99211-99215, are typically used to determine the complexity of the visit.

Which Modifiers Can Be Used With These CPT Codes?

The following modifiers can be used with CPT codes 99201-99205:

• Modifier 25: A significant, separately identifiable E/M service was provided on the same day as a procedure or other service. This modifier is often used when a patient presents with a complex medical problem that requires a more in-depth evaluation and management than would typically be required for a new patient visit.
• Modifier 51: Multiple procedures were performed during the same encounter. The modifier is appended to the code for the most significant procedure, and the other procedures are listed in the procedural notes.
• Modifier 52: The services provided were reduced or limited in some way. This modifier may be used, for example, if a patient presents with a self-limited condition that does not require a full evaluation and management.
• Modifier 59: The patient was seen by two or more physicians during the same day for the same condition. This modifier is often used in the context of a consultation.

In addition, the following modifiers may be used in certain circumstances:

• Modifier 24: Increased complexity of the medical decision-making.
• Modifier 26: Only the professional component of a procedure or service was performed, separate from the technical component. Examples are radiology, pathology, diagnostics, or split-bill arrangements.
• Modifier 32: A service was mandated by a third-party entity, such as an insurance company, worker’s compensation, or government agency.

It’s important to note that not all of these modifiers will be appropriate for every CPT code 99201-99205. The specific modifier that is used will depend on the specific circumstances of the visit.

What Are the Billing Guidelines and Documentation Requirements Specific to These CPT Codes?

The following are some general billing guidelines and documentation requirements specific to CPT codes 99201-99205:

• Accurate and thorough documentation of the patient’s history, examination findings, and medical decision-making.
• Proper documentation of the complexity of the visit to support the chosen code.
• Compliance with applicable documentation guidelines set forth by Medicare and other third-party payers.
• Clear and legible documentation signed and dated by the chiropractor who performed the evaluation and management services.
• Specific guidelines provided by payers to ensure accurate billing and avoid potential issues.

What Are Examples of ICD-10-CM Codes Often Used With These Codes?

ICD-10-CM codes are used to specify the patient’s diagnosis or reason for the encounter. Examples of ICD-10-CM codes often used in conjunction with CPT codes 99201-99205 include:

• M51.11 – Acute low back pain
• M54.5 – Neck pain
• M54.3 – Sciatica
• G55.0 – Radiculopathy, unspecified
• M53.1 – Sprains and strains of the back
• M50.9 – Pain in the back, unspecified
• M53.3 – Other torticollis
• M54.4 – Other lumbar pain
• M54.6 – Other pain in the leg

The appropriate ICD-10-CM code should accurately reflect the patient’s condition or reason for the visit.

What Are Common Mistakes Made Specific to CPT Codes 99201-99205?

Some common mistakes made when using CPT codes 99201-99205 include:

• Upcoding. Reporting a higher-level code than supported by the documentation is a common mistake to avoid. It’s important to accurately reflect the complexity of the patient encounter and not overstate the level of service provided.
• Undercoding. Conversely, undercoding is another mistake to be cautious of. Undercoding occurs when a lower-level code is reported, which does not appropriately represent the complexity of the visit. Ensure that all significant components of the encounter are documented and coded accurately.
• Incomplete documentation. Insufficient or incomplete documentation can lead to coding errors. It’s crucial to document all relevant details, including the patient’s history, examination findings, and medical decision-making. Comprehensive and thorough documentation supports the level of complexity billed.
• Lack of specificity. Specificity is vital in coding. Using generic or vague descriptions may not accurately represent the complexity of the encounter. Be specific and detailed in documenting the key elements of the visit to support the chosen E/M code.
• Ignoring time-based options. For certain patient encounters, time spent can be the controlling factor for code selection. If counseling and coordination of care dominate more than 50% of the visit, time can be used to determine the appropriate code. Document the total time spent and the activities performed during the encounter.

By understanding and avoiding these common mistakes, chiropractors can ensure accurate coding, appropriate reimbursement, and compliance with coding guidelines.

What Are Potential Audit Triggers Specific to E/M Codes 99201-99205 and How Can I Avoid Them?

Audits are a possibility in the healthcare industry, and it’s important to minimize the risk of triggering one. Here are some potential audit triggers specific to E/M codes 99201-99205 and tips to avoid them:

Inconsistent documentation: Inconsistencies in documentation, such as variations in the level of detail or inconsistent use of key elements, can raise red flags during audits. Ensure consistency in documentation practices and follow established guidelines consistently.

High utilization: Frequent use of higher-level E/M codes compared to peers can draw attention. While it’s essential to code accurately, a pattern of consistently higher-level codes without adequate justification can lead to scrutiny. Document appropriately and ensure coding reflects the complexity of each encounter.

Lack of medical necessity: Auditors look for evidence of medical necessity to support the billed services. Ensure that your documentation clearly justifies the need for the level of service provided, including the patient’s presenting problems, evaluation, and management plan.

Insufficient time documentation: If time is used as the controlling factor for E/M code selection, it’s crucial to document the total time spent on the encounter and specify the activities performed. Without clear time documentation, auditors may question the appropriateness of the selected code.

Inadequate supporting documentation: Insufficient documentation to support the billed E/M code is a common audit trigger. Ensure that your notes include all relevant information, such as history, examination findings, medical decision-making, and any additional work performed during the encounter.

By understanding these potential audit triggers and implementing best practices for accurate documentation, chiropractors can minimize the risk of audits and ensure compliance with coding and billing requirements.

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

There are a number of things that chiropractors can do to improve the accuracy and efficiency of their practice’s billing and coding processes.

These include:

• Conducting regular audits of billing and coding practices
• Staying up-to-date on changes to billing and coding regulations
• Using a cloud-based EHR and practice management software designed specifically for chiropractors

ChiroTouch can help with that. Whether your practice is cash only or accepts insurance, you’re a solo practitioner or part of a multiprovider practice, ChiroTouch can help streamline your billing processes, simplify claims management, and save time and administrative burden.

To learn more, download our free eBook, Six Ways ChiroTouch Can Improve Your Practice’s Profitability.