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.”
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