Reserve 99205 for the Sickest Patients

Level 5, new patient evaluation and management (E/M) code 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 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. 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 is appropriate to report services for only the sickest patients. It is not appropriate, for instance, for ongoing treatment of stable conditions that do not pose a threat to a patient’s life or limb.
To report 99205 appropriately, the service must call for a documented, medically necessary, comprehensive history, comprehensive exam, and medical decision-making of high complexity, based on the presenting problem for that particular date of service and the management options available to the physician for the established diagnosis.
“High complexity” or “high severity” means that the risk of morbidity (death) without treatment is high to extreme, and/or the patient has a moderate to high risk of mortality without treatment, or a high probability of severe, prolonged, functional impairment. To put it another way: The next step for the patient would be the emergency room (and perhaps a hospital admission).
The patient’s condition may be either acute or chronic, but it must pose an immediate threat to life or bodily function to support 99205. Examples of a high-risk diagnosis may include:

  • One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
  • Acute or chronic illness or injury that pose a threat to life or bodily function — multiple trauma, acute MI, pulmonary embolus, etc.
  • Abrupt change to neurological status — seizure, TIA, weakness or sensory loss

As part of the supporting documentation, the patient assessment and plan should demonstrate:

  • All diagnoses the provider is actively managing during the encounter
  • Whether the patient’s problem is stable, improved, worse, or uncontrolled for the established diagnosis
  • Diagnostic tests ordered; the rationale for ordering must be documented or easily inferred
  • Management of the patient problem (medications, surgery, etc.)

Remember, per Centers for Medicare & Medicaid Services (CMS) requirements, medical necessity is “… 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.”

Evaluation and Management – CEMC

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “Reserve 99205 for the Sickest Patients”

  1. Erin Andersen says:

    I disagree. For MDM, 2 of 3 need to meet or exceed ‘high’ to support a 5. If a patient has a new problem being worked up plus a record review is done and documented plus two other data elements (lab and rad ordered or independent review of films, etc), Risk may be dropped. Often times patients come in with a new problem that requires a lot of data to be ordered or reviewed in order to diagnose the problem. The Risk may only be moderate (new problem with uncertain prognosis or prescription medication) but that doesn’t mean that the overall medical decision making is moderate.

  2. Erin Andersen says:

    I respectfully disagree. For MDM, 2 of 3 need to meet or exceed ‘high’ to support a 5. If a patient has a new problem being worked up plus a record review is done and documented plus two other data elements (lab and rad ordered or independent review of films, etc), Risk may be dropped. Often times patients come in with a new problem that requires a lot of data to be ordered or reviewed in order to diagnose the problem. The Risk may only be moderate (new problem with uncertain prognosis or prescription medication) but that doesn’t mean that the overall medical decision making is moderate.
    Thank you.

  3. Connie says:

    99205 is a new pt visit and all 3 areas must meet the requirements of Comprehensive for history, Comprehensive for Exam and High medical decision making.

  4. Rita Donohue says:

    If what you are saying is true, then why does the MDM portion only require 2 of 3 areas instead of all 3? It is possible to score a high level in the number of diagnoses or treatment options, and, also in the amount/complexity of data to be reviewed, with a lower level for the table of risk. This would still support a high level of MDM according to the guidelines.

  5. Felicia Owens says:

    It is so true that the severity of the conditions should drive the selection of 99205, however the condition itself does not always have to be life threatening in order for high decison making to be documented. Chronic conditions such as diabetes, hypertension and kidney disease even if they are under control require review of records, labs, meds, and at times consulting with other treating Physicians; this is especially true for new patients. In these cases, a 99205 chould still be supported if the amount of data reviewed and number of conditions were both high even if the risk was only moderate. The risk category is a good guide for determining medical necessity but it shouldn’t have to be used as the only factor in decision making.

  6. Kevin Solinsky says:

    Risk is what supports medical necessity. According to Centers for Medicare & Medicaid Services, medical necessity not medical decision making is the over arching factor in determining the level of service. Medical necessity is based on the presenting problem. Thus if you use Column 1 of the Table of Risk as the driving force for medical necessity you can never go wrong.
    Thank You

  7. Erin says:

    What about when time is documented for 60 minutes and provider spent over 50% of the visit in counseling? Does the dx still need to be a ”high severity dx?”

  8. Robert Colby says:

    I agree with everyone disagreeing, as the MDM chart only requires two of three.
    Also, if 31 minutes of a 60 minute appointment is spent counseling and coordinating care, then time becomes the overriding factor for deciding the E&M code.
    (60 minutes! What? Am I the only one here who works with psychiatrist?)

  9. Erin says:

    I have a specialty type program for pediatric obesity that i code for and the provider’s initial visit is always an hour with the patient. It takes alot of time to educate on all the co-morbidities of obesity, diet management and exercise to an adult, let alone a child. The initials are always an hour but she is not a psychiatrist. Just a specialized program for pediatric obesity. There is a counselor who does see the pt for behavioral health related to obesity and such.
    For a new patient all 3 criteria are supposed to be met. This is in the guideline in CPT under each level. 2/3 is only for established pt. This article looks to be in regards to New patient code 99205, Am i missing something on the MDM for a new patient?

  10. Robert Colby says:

    Erin – I apologize, we posted simultaneously as I did not see your post before I posted. I believe we are on the same page though.
    I am fairly certain that the time-based guideline was put in place specifically for specialties (ie psychiatrists and childhood obesity specialists). I think this article is meant for family practice physicians, who probably should reserve 99205 for their sickest patients. I’m just comforted to know that I am not the only person that completely disagrees with it.
    *The 2/3 I was referring to are the components of medical decision making (number of diagnosis or treatment options, amount & complexity of data, and highest risk)

  11. Erin says:

    Thank-you Robert, I also code for Family practice and rarely see the 99205 there. They see alot of chronically ill patients and its rare that I see a new patient come through. But the other program has new patients fairly regularly.
    I understand now on the MDM table that you were referring to. I still mix up the MDM table and the Leveling table occasionally! Thanks for clarifying!

  12. Donna says:

    I am in agreement with Kevin. Medical necessity is the overaching criterion for choosing a code. If a patient does have an acute or chronic illness but it is stable at the time of the visit, you would have an established problem stable/improved. How can you justify billing a 99205/99215?

  13. Sue says:

    I have this issue with my providers all the time. The MDM part where you only need 2 out of the 3 tables to meet or exceed. My providers always have several dx so they get a 4 in the dx table and a 4 in the data table, and don’t even consider the third table. They keep saying 2 of 3. I point out medical necessity and they point out that it doesn’t say that.
    When I explain it’s based on medical necessity they asked then why does it say 2 of 3?
    (dx table, data table, risk table)
    They always want to code the 99205 or 99215.

  14. Carl says:

    i would have to say this is an interesting topic. agreement on article, there should be no way a level 5 is used in a pcp office or clinic; if pt is that ill they are directed to er so doc has no liability, therefore the hospital e&m code is used for the day pcp is out of luck, collect co-pay and call it a day; or bill level 1 for just seeing pt and calling ambulance. if no one has noticed, CMS has this on their radar and will alert the RACs Zips, and any other group of auditors to start looking for this. it is a no brainer for auditors, purely data mining – pull all level 5 visits with POS 11. easy money for RAC company, easy money for CMS to recoup cost of ACA, icd-10, increased enrollment of MC, etc.
    Physicians, be forewarned, if you conitinue to bill for any level 5, you will be audited, and will be paying back the fee you received plus interest, yeah we know, “well they paid for it before”. that was then, this is now.
    not to be demeaning, but only to forwarn people, it is on the OIG workplan.

  15. Jackie says:

    What about an urgent care clinic? We have new patients all the time and we basically have to do a full exam on the person.

  16. Tina says:

    I think where the level 5 has the most problem is in the MDM- you would still do the comprehensive exam & history with a level 4, but even in urgent care would you be doing any cardiac imaging studies, diagnostic endoscopies or any major or emergency surgeries required for the level 5- these would be referred out to an ER or hospital?

  17. Sherlet says:

    99205 NEW patient code just to clarify
    The 2 out of 3 requirement pertains only to ESTABLISHED patients .
    3 out of 3 is required for NEW patients. Medical Necessity is the overarching criteria
    for all code selections .
    99205 requires a comprehensive hx, & exam, and HIGH MDM. The audit sheet bullets can add up
    to a HIGH medical decision making process if there are multiple items done & consults or obtaining history. Question is whatʻs the Nature of the presenting problem? for a 99205 it must be a severe problem that “poses a threat to life or limb” or is a life threatening problem. Remember a life threatening problem that resolves due to treatment with the patient going home still can justify a 99205
    examples: asthmatic attack, anaphalyxis. Remember your primary (1st listed) ICD code needs to support the E&M 99205 unspecified or NOS codes wonʻt cut it.

  18. Patti Cibor says:

    If a patient is being seen for therapy in a community health center – and then sees one of the MD’s in the medical clinic for a medical problem – would it be billed as an established patient as patient currently being seen in behavioral health – or would it be new? Both providers bill under the same tax id#.
    would be very appreciative if someone could shed some light!

  19. Billy W Oliver says:

    If this is true how can you decide one way or another because if the person can’t talk while examing them for 25 minutes or even a hour that’s making a exemptions I can explain farther if needed but the way medical professional is I have problem it’s odd my wife to phychiatry hospital talking but now for past 2 years lucky to say 6 words I don’t trust medical people right now for that reason