cpt 99212

CPT Code 99212 – Descriptio, Billing Guidelines & Clinical Examples

This article will define CPT Code 99212, explain the medical necessity to report CPT 99212, the guidelines and clinical examples of CPT 99212.

CPT Code 99212 Description

CPT Code 99212 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99212):

Outpatient visit for assessment and treatment of an established patient, which has the requirement of a medically appropriate history and / or examination and easy medical decision making.

CPT 99212 requires a minimum of 2 of these 3 components to be present in the medical record:

Component 1: A problem focused history

Component 2: A problem focused examination

Component 3: Straightforward medical decision making

A stabilised patient is one who has been given professional services from a qualified doctor / healthcare professional or another qualified doctor / healthcare professional of exactly the same specialty and subspecialty belonging to the same practice group, in the last 3 years.

In the event that a qualified physician / healthcare practitioner is on call or covers another qualified physician / healthcare practitioner, the meeting with the patient will be restricted as would have been performed by the unavailable qualified physician / healthcare practitioner.

When time is used for code selection, 10-20 minutes of the total time to match date are spent.

Problem Focused History

Documentation Required:

Chief Complaint

Brief History of Current Illness

Problem Focused Exam

Documentation Required: Limited examination of the affected body area or organ system.

Straightforward MDM

Documentation required (two of the following three must be met or passed):

Minimum number of diagnoses or management options.

No or minimum amount and / or complexity of data to be reviewed.

Minimum risk of important complications, morbidity and / or fatality.

A good rule of thumb for determining whether to use CPT code 99212 is to evaluate whether the issue in question is self-limiting or minor. Also, be sure that the visit lasted 10 minutes or longer and combines two of the three components.

CPT 99212 Medical Decision Making

The Medical Decision Making (MDM) level, based on 2 of 3 MDM elements is straightforward with no complications. The elements of MDM include:

The complexity & number of problems addressed:
Minimal, one, self-limited or minor problem.

Quantity and / or complexity of data to analyse and review:
Minimal or zero

Risk of complications and / or morbidity or fatality from patient management:
Minimal risk of morbidity due to additional diagnosis, tests or treatment

CPT 99212 RVUs

The following points show all RVUs for the first quarter of 2021 and the fourth quarter of 2020 for CPT code 99212.

The RVUs for MPFS facilities are typically less than the non-facility (office) RVUs because when the physician implements services in the facility, the doctor is responsible for lower costs of practice.

Final reimbursement amounts for E / M services will be dependant upon more than these RVUs.

2020 Q4 RVUs – 1.28 (Non-Facility) – 0.73 (Facility)

2021 Q1 RVUs – 1.67 (Non-Facility) – 1.06 (Facility)

A policy update in the MPFS 2019 last rule that had a lot of backlash from suppliers was a decision to pay a one-time fee, named a combined fee. In other words, Medicare wanted to pay the equal rate for the new patient codes CPT 9920299204, regardless of the code reported.

Medicare would pay an additional one-time fee for established patient CPT codes 99212 – 99214. Level 5 visits (CPT 99205 and 99215) will have different fees to mirror the increased complexity represented by those CPT codes.

CPT Code 99212 Examples

Example 1

Office visit for an 11-year-old, established patient, seen in follow-up for mild comedonal acne of the cheeks on topical desquamating agents. (Dermatology/Family Medicine/Pediatrics)

Example 2

Office visit for a 10-year-old female, established patient, who has been swimming in a lake, now presents with a one-day history of left ear pain with purulent drainage.(Family Medicine)

Example 3

Office visit for a child, established patient, with chronic secretory otitis media. (Otolaryngology/Head & Neck Surgery)

Example 4

Office visit for an established patient seen in follow-up of clearing patch of localized contact dermatitis. (Family Medicine/Dermatology)

Example 5

Office visit for an established patient returning for evaluation of response to treatment of lichen planus on wrists and ankles. (Dermatology)

Example 6

Office visit for an established patient with tinea pedis being treated with topical therapy. (Dermatology)

Example 7

Office visit for an established patient with localized erythematous plaque of psoriasis with topical hydration. (Dermatology)

Example 8

Office visit for a 50-year-old male, established patient, recently seen for acute neck pain, diagnosis of spondylosis, responding to physical therapy and intermittent cervical traction. Returns for evaluation for return to work. (Neurology)

Example 9

Office visit for an established patient with recurring episodes of herpes simplex who has developed a clustering of vesicles on the upper lip. (Oral & Maxillofacial Surgery)

Example 10

Evaluation of a 50-year-old male, established patient, who has experienced a recurrence of knee pain after he discontinued NSAID. (Anesthesiology/Pain Medicine)

Example 11

Office visit for an established patient with an irritated skin tag for reassurance. (Dermatology)

Example 12

Office visit for a 40-year-old, established patient, who has experienced a systemic allergic reaction following administration of immunotherapy, The dose must be readjusted. (Allergy & Immunology)

Example 13

Office visit for a 33-year-old, established patient, for contusion and abrasion of lower extremity. (Orthopaedic Surgery)

Example 14

Office visit for a 22 –year-old male, established patient, one month after I & D of “wrestler’s ear”. (Plastic Surgery)

Example 15

Office visit for a 21-year-old, established patient, who is seen in follow-up after antibiotic therapy for acute bacterial tonsillitis. (Otolarygology/Head & Neck Surgery)

Example 16

Office visit for a 4-year-old, established patient, with tympanostomy tubes, check-up. (Otolarynology/Head & Neck Surgery)

Example 17

Office visit for an established patient who has had needle aspiration of a peritonsillar abscess. (Orolaryngology/Head & Neck Surgery)

Example 18

Follow-up office examination for evaluation and treatment of acute draining ear in a 5-year-old with tympanotomy tubes. (Otolaryngology/Head & Neck Surgery)

Example 19

Office visit, established patient, 6-year-old with sore thorat and headache. (Family Medicine/Pediatrics)

Example 20

Office evaluation for possible purulent bacterial conjunctivitis with one-to two-day history of redness and discharge, 16-year-old female, established patient. (Pediatrics/Internal Medicine/Family Medicine)

Example 21

Office visit for a 65-year-old female, established patient, returns for three-week follow-up for resolving severe ankle sprain. (Orthopaedic Surgery)

Example 22

Office visit, sore throat, fever, and fatigue in a 19-year-old college student, established patient. (Internal Medicine)

Example 23

Office visit with a 33-year-old female, established patient, recently started on treatment for hemorrhoidal complaints, for re-evaluation. (Colon & Rectal Surgery)

Example 24

Office visit for a 27-year-old female, established patient, with complaints of vaginal itching. (Obstetrics & Gynaecology)

Example 25

Office visit for a 65-year-old, established patient, with eruptions on both arms from poison oak exposure. (Allergy & Immunology/Internal Medicine)

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