How To Use CPT Code 99212

CPT code 99212 is a procedural code used for office or other outpatient visits for the evaluation and management of established patients, requiring a medically appropriate history and/or examination and straightforward medical decision making. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, modifiers, common misconceptions, comparisons to other codes, and examples of cases when CPT 99212 can be used.

1. What is CPT 99212?

CPT 99212 is a procedural code used in medical billing for office or other outpatient visits involving the evaluation and management of established patients.

This code is applicable when the visit requires a medically appropriate history and/or examination and straightforward medical decision making.

The total time spent on the date of the encounter should be between 10-19 minutes, and the level of medical decision making involved should be straightforward.

2. 99212 CPT Code Description

The official description of CPT 99212 is: “Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.”

3. Procedure

The procedure for CPT 99212 involves the following steps:

1. Reviewing tests and preparing for the patient visit.
2. Performing the exam or evaluation.
3. Counseling and educating the patient or caregiver.
4. Ordering tests.
5. Communicating with other healthcare providers.
6. Documenting the encounter.
7. Interpreting and communicating results.
8. Coordinating care.

4. Qualifying circumstances

Patients eligible to receive CPT code 99212 services are established patients who require a medically appropriate history and/or examination and straightforward medical decision making during an office or other outpatient visit. The total time spent on the date of the encounter should be between 10-19 minutes.

5. When to use CPT code 99212

It is appropriate to bill the 99212 CPT code when the following criteria are met:

• The patient is an established patient.
• The visit takes place in an office or other outpatient setting.
• A medically appropriate history and/or examination is required.
• Medical decision making is straightforward.
• The total time spent on the date of the encounter is between 10-19 minutes.

6. Documentation requirements

To support a claim for CPT 99212, the following information should be documented:

• Patient’s demographic information.
• Date of service.
• Location of service (office or other outpatient setting).
• Medically appropriate history and/or examination performed.
• Level of medical decision making (straightforward).
• Total time spent on the date of the encounter (10-19 minutes).
• Details of the evaluation and management services provided, including any tests ordered, counseling, and education provided to the patient or caregiver.
• Any communication with other healthcare providers.
• Results of any tests and their interpretation.
• Coordination of care.

7. Billing guidelines

The billing guidelines and rules that apply to CPT code 99212 include:

• Only bill for established patients.
• Ensure the visit takes place in an office or other outpatient setting.
• Document a medically appropriate history and/or examination.
• Ensure medical decision making is straightforward.
• Document the total time spent on the date of the encounter (10-19 minutes).
• Include all necessary documentation to support the claim, as outlined in the documentation requirements section.

8. Modifiers

Modifiers can be used with CPT code 99212 in certain cases, such as:

• Modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service. This modifier is used when a separate and distinct E/M service is provided on the same day as another procedure or service. It indicates that the E/M service is not part of the pre- or post-operative care and should be reimbursed separately.
• Modifier 95: Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. This modifier is used when the E/M service is provided through telemedicine, using real-time audio and video communication between the patient and the healthcare provider. It indicates that the service was provided remotely and not in-person.
• Modifier 21: Prolonged evaluation and management services. This modifier is used when the E/M service provided is prolonged beyond the typical time associated with CPT 99212. It indicates that the service took longer than expected due to the complexity of the patient’s condition or other factors.
• Modifier 22: Unusual procedural services. This modifier is used when the E/M service provided is substantially greater than typically required for CPT 99212. It indicates that the service was more complex or time-consuming than usual, and additional reimbursement may be warranted.

9. Examples

Here are 10 examples of cases when 99212 CPT code can be used and why:

1. A patient with a minor skin rash visits their primary care physician for evaluation and management. The visit requires a brief examination and straightforward medical decision making, with a total time spent of 15 minutes.
2. An established patient visits their healthcare provider for a routine follow-up on their well-controlled hypertension. The visit involves a brief history, examination, and straightforward medical decision making, with a total time spent of 12 minutes.
3. A patient with a history of migraines visits their healthcare provider to discuss a recent increase in headache frequency. The visit requires a brief history, examination, and straightforward medical decision making, with a total time spent of 18 minutes.
4. An established patient visits their healthcare provider for a follow-up on their stable diabetes management. The visit involves a brief history, examination, and straightforward medical decision making, with a total time spent of 10 minutes.
5. A patient with a minor ankle sprain visits their healthcare provider for a follow-up evaluation. The visit requires a brief examination and straightforward medical decision making, with a total time spent of 14 minutes.
6. An established patient visits their healthcare provider for a routine follow-up on their well-controlled asthma. The visit involves a brief history, examination, and straightforward medical decision making, with a total time spent of 11 minutes.
7. A patient with a history of seasonal allergies visits their healthcare provider to discuss recent symptoms. The visit requires a brief history, examination, and straightforward medical decision making, with a total time spent of 17 minutes.
8. An established patient visits their healthcare provider for a follow-up on their stable anxiety management. The visit involves a brief history, examination, and straightforward medical decision making, with a total time spent of 13 minutes.
9. A patient with a minor ear infection visits their healthcare provider for evaluation and management. The visit requires a brief examination and straightforward medical decision making, with a total time spent of 16 minutes.
10. An established patient visits their healthcare provider for a routine follow-up on their well-controlled gastroesophageal reflux disease (GERD). The visit involves a brief history, examination, and straightforward medical decision making, with a total time spent of 19 minutes.