![]() ![]() Reviewers may assist with selecting codes, however, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer.Select code that best represents the services furnished during the visit.The Key Components – History, Examination, and Medical Decision Making – must be considered in determining the appropriate code (level of service) to be assigned for a given visit. Select the appropriate code based on the level of service provided when you are seeing a new patient for initial evaluation of a neuromusculoskeletal condition or injury.ĭocumentation in the clinical record must support the level of service as coded and billed. Billing Instructions: Bill 1 unit per visit. Typically, 60 minutes are spent face-to-face with the patient and/or family. Usually, the presenting problem(s) are of moderate to high severity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Typically, 45 minutes are spent face-to-face with the patient and/or family.īilling Instructions: Bill 1 unit per visit.ĬPT 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history a comprehensive examination and medical decision making of high complexity. Billing Instructions: Bill 1 unit per visit.ĬPT 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history a comprehensive examination and medical decision making of moderate complexity. Typically, 30 minutes are spent face-to-face with the patient and/or family. Usually, the presenting problem(s) are of moderate severity. Billing Instructions: Bill 1 unit per visit.ĬPT 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history a detailed examination and medical decision making of low complexity. Typically, 20 minutes are spent face-to-face with the patient and/or family. Usually, the presenting problem(s) are of low to moderate severity. ![]() Billing Instructions: Bill 1 unit per visit.ĬPT 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history an expanded problem focused examination and straightforward medical decision making. Typically, 10 minutes are spent face-to-face with the patient and/or family. Usually, the presenting problem(s) are self limited or minor. CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history a problem focused examination and straightforward medical decision making. ![]()
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