Reporting Level 5 E/M Code 99205

by | Last updated on Apr 3, 2024 | Published on Jun 27, 2014 | Medical Coding

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CPT code 99205 is a high-level evaluation and management code used for the evaluation and management of new patients, for both office and outpatient visits. CPT code 99205 can be selected for new patient visits lasting 60+ minutes on the date of encounter. The total time required for reporting 99205 is 60-74 minutes. Reporting CPT code 99205 accurately is often difficult for coders. This is where a professional medical coding company can support.

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Documentation Requirements for CPT Code 99205

Code99205 requires 3 key components:

  • High-level medical decision-making: The evaluation and management of a patient demand intricate decision-making processes. This involves properly analyzing and interpreting medical records, diagnostic tests, and relevant information to formulate an accurate diagnosis and treatment plan.
  • Thorough medical history or examination: Proper assessment of a patient’s condition necessitates a comprehensive history or examination. This involves gathering details about the patient’s medical background, current symptoms, past treatments, and any other crucial factors influencing their healthcare.
  • Session duration typically ranging from 60-74 minutes: CPT code 99205 denotes an extended duration of service compared to other evaluation and management codes. The session duration encompasses both face-to-face and non-face-to-face time dedicated to the patient encounter.

While the new patient codes (99201–99205) require that all three key components (history, exam and medical decision making) be satisfied, the established patient codes (99211–99215) require that only two components of the three key be satisfied.

What is High Risk Diagnosis?

The terms “high complexity/high severity” signifies that the patient’s risk of death/morbidity is high – extreme and/or the patient has a moderate – high risk of death without treatment or a high probability of severe, prolonged, functional impairment. So to justify the use of 99205, the patient’s condition, whether acute or chronic must pose an immediate threat to life or physical function.

High risk diagnosis may be:

  • Sudden change to neurological status such as weakness/sensory loss, TIA (Transient Ischemic Attack), seizure
  • Chronic illnesses with severe progression, worsening or side effects of treatment
  • Acute/chronic injury or illnesses that pose a threat to physical function or life itself such as acute MI, multiple trauma, pulmonary embolus

Common Mistakes to Avoid in Billing CPT Code 99205

Avoiding common mistakes are crucial when billing CPT Code 99205. Ensure accurate reimbursement and compliance with professional coding guidelines.

Here are some common mistakes to avoid:

  • Insufficient documentation: One of the most common mistakes is not providing enough documentation to support the level of service billed. Ensure that the documentation includes a detailed history of present illness, comprehensive review of systems, comprehensive examination of multiple organ systems, and medical decision making of high complexity.
  • Overbilling: Billing for a level of service higher than warranted by the patient encounter can lead to overbilling and potential audits. Make sure the documentation accurately reflects the complexity of the patient’s condition and the level of service provided.
  • Under coding: Conversely, under coding occurs when providers bill for a lower level of service than warranted by the patient encounter. Ensure that the documentation accurately reflects the complexity of the patient’s condition to avoid under coding and potential loss of revenue.
  • Lack of medical necessity: Ensure that the documentation clearly demonstrates the medical necessity of the services provided. Medical necessity is essential for justifying the level of service billed and ensuring reimbursement.
  • Failure to document time spent: CPT code 99205 requires encounter time. So, keep track of the time you spend with the patient. Failure to document the total time spent with the patient and the specific amount of time spent on counseling or coordination of care can lead to billing errors and potential denials.
  • Mixing-up patient status: This code is specifically designated for new patients, so it’s crucial to differentiate it from established patient codes to ensure accurate billing and documentation. Familiarizing the distinct criteria for each code can streamline the process and prevent any potential errors in reimbursement.

By avoiding these common mistakes and ensuring accurate documentation, healthcare providers can bill CPT Code 99205 appropriately, leading to accurate reimbursement and compliance with coding guidelines. Modifiers used for 99205 depend on specific billing circumstances. For example, modifier “-25” is of use, if a significant and separately identifiable service is provided on the same day. Billing 99205 with other codes depends on the services provided and payer rules. Proper use of modifiers and adherence to billing guidelines are essential when billing for multiple services.

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Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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