E/M code 99205 is used to report office or other outpatient visit for the evaluation and management of a new patient, and requires 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
This code can be used only when reporting services provided to the sickest patients. It is inappropriate to use this code to signify treatment provided for ongoing stable conditions that do not pose any serious threat to the patient. 99205 can be reported when the service provided requires a documented, medically necessary, comprehensive history, comprehensive exam and medical decision making of high complexity on the basis of the presenting problem for that particular date of service and the management options that are available to the physician for the diagnosed condition.
CMS defines medical necessity as “. . . the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted”.
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.
To ensure appropriate reimbursement, the documentation should contain:
- All diagnoses that the provider is managing during the patient encounter
- Information whether the patient’s problem is improved, stable, worse or uncontrolled for the established diagnosis
- Details of diagnostic tests ordered – the reason for ordering must be clearly documented or easily inferred
- How the patient’s problem is managed (surgery, medications etc.)