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Exception for Evaluation and Management Services Furnished in Certain Primary Care Centers


Medicare may grant a primary care exception within an approved GME Program in which you, the teaching physician, are paid for certain E/M services the resident performs when you are not present. The lower and mid-level E/M services included under the primary care exception are given below.

New Patient

99201    Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers 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 self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

99202    Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers 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 low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.

99203    Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers 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 severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 

Estabilished Patient

99211    Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

99212    Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers 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 self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

99213    Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers 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 low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

The Healthcare Common Procedure Coding System (HCPCS) codes included under the primary care exception are listed below.

HCPCS Code G0402 Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first 12 months of Medicare enrollment (effective January 1, 2005)

HCPCS Code G0438 Annual wellness visit, including personal preventive plan service, first visit (effective January 1, 2011)

HCPCS Code G0439 Annual wellness visit, including personal preventive plan service, subsequent visit (effective January 1, 2011)

For the exception to apply, a primary care center must attest in writing that all of the following conditions are met for a particular residency program.......Read more 
 

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