Medical billing is a highly complex process. It is not easy for many doctors, business professionals, and learners. CPT codes are crucial to billing and getting reimbursed precisely. There are so many codes, but one of the most common ones is CPT code 99213. However, these codes play a vital role in everyday medical practice. It means that when you pay for a particular service, only healthcare providers are paid appropriately.
What are CPT Codes?
CPT code refers to the Current Procedural Terminology (CPT) Disease. Healthcare providers use these codes to describe medical services and procedures. The American Medical Association oversees the CPT codes to make sure the medical fraternity uses the exact wording. It generalizes what doctors do to ensure that everyone, from doctors and insurance companies to the patient, knows what the services are.
Why are CPT Codes Important?
Telemedicine app development company provide CPT codes to follow standardized language that healthcare providers, patients, and payers (such as insurance companies) can use. It will ensure clear communication. CPT codes are employed for billing purposes.
Types of CPT Codes
There are three types of CPT codes.
Category I: CPT codes are utilized in procedures or services that are performed often.
Category II: Supplementary tracking codes, which help for performance management.
Category III: Emerging technology, services, and procedure codes.
E/M Codes Overview
Physician-patient encounter services fall under the scope of group Evaluation and Management Services. Code 99213 is an example of this type of code. The “CPT” code is merely a short term for the Current Procedural Terminology code. CPT codes describe procedures, both surgical and non-invasive. E/M services classifications take into account variables like the difficulty in dealing with a patient’s problem, history obtained, examination, and decision-making.
Moreover, evaluation and management codes promote uniformity in billing across all healthcare settings. Such a process ensures that healthcare providers are paid for their time and expertise resources during each encounter with the patient.
Levels of E/M Codes
E/M codes have multiple levels that depend on the complexity of the visit and the time taken. For established patients seen in the office or other outpatient departments, the range begins at 99211 and moves to 99215.
99211: Low-level issues; low-level visits.
99212: Problem-focused.
99213: Expanded problem-focused.
99214: High level of documentation.
99215: Comprehensive.
When to Use CPT Code 99213
1. Appropriate Situations
2. Examples of Visits
3. Inappropriate Use
Decomposing the Elements of CPT Code 99213
To properly use CPT code 99213, you must be familiar with its three components: History, Examination, and Medical Decision Making. Of these three elements, at least two must be eligible to use this code.
1. History
Extended Problem-Focused History
This type of history includes:
Chief Complaint (CC): The main reason for the patient’s visit.
History of Present Illness (HPI): A brief description of the symptom or issue (1-3 words).
Review of Systems (ROS): A problem-specific review directly related to the presenting issue.
Past, Family, and Social History (PFSH): Included only if relevant to the problem.
Example:
CC: “Follow-up on hypertension.”
HPI: Occasional headaches at home; blood pressure recorded as 130/85.
ROS: Afebrile, no chest pain, dizziness, or shortness of breath reported.
2. Oriented History
Enlarged Problem-Oriented History
This type of history includes a detailed evaluation of the following medical billing and coding:
Focused History: Assessment of the affected area or organ system, along with related systems (covering at least 2-7 systems or areas).
Vital Signs: These include blood pressure, heart rate, and respiratory rate.
Cardiovascular Exam: Normal heart sounds; no murmurs detected.
Respiratory Exam: Lungs clear upon auscultation.
3. Medical Decision-Making
Low Complexity
This level of medical decision-making involves:
Number of Diagnoses or Management Options: Few, typically one stable chronic condition.
Quantity and Complexity of Data Assessed: Limited data, such as evaluating basic lab studies.
Risk of Complications: Low risk for the patient’s condition or treatment plan.
Example:
Adjusting an antihypertensive dosage.
Ordering routine laboratory tests.
CPT 99213 Billing Guidance
Documentation Requirements
It is essential to ensure that the level of service matches the documentation. Medical billing code 99213 requires two of the three major components to be documented.
Modifiers
Modifiers are two-digit codes added to a CPT code to give additional detail. Modifier 25 is used for a significant, separate E/M service performed on the same day as another procedure.
Avoiding Common Pitfalls
Upcoding, or billing for a higher level of service than performed, is fraudulent and punishable. Undercoding can lead to revenue loss and missed opportunities.
Time-Based Coding
Time only determines the 99213 CPT code if the primary focus is on counselling or care coordination. If counselling accounts for more than half of the appointment, it must be documented.
Medical Necessity
Medical necessity is key in selecting the proper level of service. The care provided must be reasonable and necessary for the diagnosis or treatment of the patient’s condition. Even for higher levels of service, adequate documentation of necessity is required. Avoid providing or billing for medical services that are not justified by the patient’s condition.
Practice Tips in Accurate Documentation
Proper documentation is vital for accurate billing and better patient care. Clearly record the chief complaint, relevant findings, and diagnoses in a specific and descriptive manner.
Timeliness
Staying Current on Changes
Keeping Current
Knowledge of Compliance and Audits
Need for Compliance
Legal Protection: This is because of the law and the reduction in the risk due to the law.
Financial Integrity: Correct reimbursement without fines being imposed.
Reputation Management: A maintained relationship with the trust of patients and payers.
Documentation Audit: Fields to be analyzed regularly to update the codes for the records.
Internal Controls: Put controls and checks in billing.
External Audits: Any external audits that prove ways of improvement.
Technology and CPT Code 99213
Technology can help with accurate coding and documentation with medical billing code 99213.
Electronic Health Records (EHR)
Templates: Utilize templates specific to EHR and CPT code 99213; therefore, all elements are met.
Alerts: Set up to alert missing documentation components.
Efficiency: Such a process streamlines the time lost on documentation.
Coding Software
Support: Provides suggestions for applicable codes based on documentation.
Updates: Includes any new coding updates automatically.
Error Reduction: Helps minimize the chances of coding mistakes through internal checks.
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