By Christina Hussan -- When a provider has not seen a patient for three or more years, it is permitted to bill for a new patient office visit.  Actually, the time period is “three years plus one day,” to be exact, but the rules change when the patient has seen other providers in the group during the interim.  It goes like this:  If a patient has not seen any provider in a practice in three years (plus one day!), then it is appropriate to bill for a new patient office visit, but if any provider in the practice has seen the patient at any time within that three year period, it is required that the billing go through for an established patient visit.

It’s also important that established patient visits be coded based on the criteria specific to each code.  Here are the guidelines for billing established patient office visits:

99215 vs. 99205

99215 – requires at least 2 of these 3 key components:

• A comprehensive history;
• A comprehensive exam;
• Medical decision making of high complexity.
• Usually, the presenting problem(s) are of moderate to high severity.  Physicians typically spend 40 minutes face-to-face with the patient and/or family.

99205 -- requires these 3 key components:

• A comprehensive history;
• A comprehensive exam;
• Medical decision making of high complexity
• Usually, the presenting problem(s) are of moderate to high severity.  Physicians typically spend 60 minutes face-to-face with the patient and/or family. 

99214 vs. 99204 

99214 – requires at least 2 of these 3 key components: 

• A detailed history;
• A detailed exam;
• Medical decision making of moderate complexity. 
• Usually, the presenting problem(s) are of moderate to high severity.  Physicians typically spend 25 minutes face-to-face with the patient and/or family. 

99204 -- requires these 3 key components: 

• A comprehensive history;
• A comprehensive exam;
• Medical decision making of moderate complexity 
• Usually, the presenting problem(s) are of moderate to high severity.  Physicians typically spend 45 minutes face-to face with the patient and/or family. 

99213 vs. 99203 

99213 –  requires at least 2 of these 3 key components: 

• An expanded problem focused history;
• An expanded problem focused exam;
• Medical decision making of low complexity. 
• 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. 

99203 -- requires these 3 key components: 

• A detailed history;
• A detailed exam;
• Medical decision making of low complexity. 

99212 vs. 99202 

99212 – requires 2 of these 3 key components: 

• A problem focused history;
• A problem focused exam;
• Straightforward medical decision making. 
• 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 -- requires these 3 key components: 

• An expanded problem focused history;
• An expanded problem focused exam;
• Straightforward medical decision making. 
• 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. 

99211 vs. 99201 

99211 – Usually, the presenting problem(s) are minimal.  Typically, 5 minutes are spent performing or supervising these services. 

99201 -- requires these 3 key components: 

• A problem focused history;
• A problem focused exam;
• Straightforward medical decision making 
• Usually, the presenting problem(s) are self-limited or minor.  Physicians typically spend 10 minutes face-to-face with the patient and/or family. 

Prolonged Services 

Sometimes, the provider will spend even more time with a patient and/or the family than is indicated in the parameters for the appropriate code.  In these cases, the provider can and should seek reimbursement for the higher time investment using codes for prolonged services: 

For example, if a visit meets the parameters for billing code 99214, but the provider spent an hour and 20 minutes with the patient, that does not automatically mean that the visit gets bumped up to a 99215, especially if the decision making level was still of moderate – not high—complexity.  In this case, it’s appropriate to bill for the 99214 and also bill for prolonged services with 99354: 

99354 – Prolonged service requiring direct patient contact beyond the usual service (first hour) 

99355 – each additional 30 minutes 

Using these evaluation and management codes correctly is an integral part of getting paid appropriately for services rendered, so pay attention to the guidelines and code to the highest specificity for the situation, and make sure that coding decisions are supported by documentation in the patient’s record.