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OFFICE VISIT: Low complexity, vaccine counseling with no vaccine administration A 48-year-old patient with private insurance visits his provider for his annual comprehensive health and wellness visit, which includes a review of patient past medical history, an annual physical exam, and coordination of follow-up monitoring of high cholesterol and pre-diabetes. This patient is an established patient and is indicated for an influenza vaccine and a tetanus, diphtheria, pertussis (Tdap)/ tetanus and diphtheria (Td) booster. The physician spends 5 minutes prior to the visit, on the date of encounter, reviewing the patient’s history, including looking for prior immunizations for this patient in the state immunization information system (IIS). At the visit, the provider counsels the patient on the booster recommendation and the importance of annual influenza vaccination. The patient decides not to get either vaccine. The total time spent on the encounter lasts 35 minutes (30 minutes visit and 5 minutes of work prior to the visit). Explanation of code selection Because no vaccine was administered, vaccine administration codes cannot be used for vaccine counseling. The correct code is the preventive visit code which is linked to age [99395 (age 18-39), 99396 (age 40-64), 99397 (age 65 and older)]. No specific times are associated with this code. Because these codes are not time-based, no changes are required relative to the AMA changes. Under the new coding rules, the non “face-to-face” time spent on the date of the encounter can be counted although the total time results in the same code being previously chosen (i.e., the time calculation has changed.)
1. Patient Information Patient Age : 48 years old. Visit Type : Comprehensive annual health and wellness visit (routine preventive care). Established Patient : The patient has been seen by this provider before. Services Provided : o Review of medical history. o Physical exam.
o Follow-up discussion for managing high cholesterol and pre-diabetes. o Vaccine counseling (influenza vaccine and Tdap/Td booster). Time Spent : o 5 minutes pre-visit: Reviewing patient history and immunization records. o 30 minutes during the visit: Counseling and addressing the patient’s concerns. o Total Time : 35 minutes.
2. Important Coding Considerations Preventive Visit Codes The Preventive Medicine Services Visit codes (CPT 99381–99397 ) are used for annual physicals. These codes are age-specific and include routine exams, health counseling, and guidance. For this patient: o CPT Code 99396 is correct for an established patient aged 40–. Time-Based Coding Changes The non-face-to-face time spent on the date of service (e.g., reviewing records before the visit) can now be included in the total time calculation, even though this doesn’t change the code selection for preventive visits like 99396. However, Preventive Medicine codes are not time-based ; they are linked to the age and the purpose of the visit. Vaccine Counseling Without Administration The provider counseled the patient on vaccines, but no vaccines were administered. Vaccine administration codes (e.g., 90460 , 90471 ) cannot be used because they are only applicable when a vaccine is actually given. The counseling is bundled into the preventive visit code ( 99396 ) and doesn’t require separate billing. 3. Explanation of Code Selection CPT Code Description Reason 9939 6 Preventive Medicine Service, Established Patient, Age 40– This covers the annual wellness visit for an established patient aged 40–64. It includes the history review, physical exam, and preventive counseling provided.
performed, and a diagnosis is reached. The physician prescribed medication and counsels the patient on risks and benefits. Following the face-to-face visit, the physician enters documentation into the electronic health record. The total time on the date of the encounter related to the additional office visit is 25 minutes. Explanation of code selection Because there is a separately identifiable evaluation and management service performed, the claim would include the preventive counseling CPT code (for the discussion on hepatitis B vaccination) plus a code for an office visit (for the complaint of lower abdominal pain). You would append the CPT code for the office visit (99213) with modifier 25 (Separately Identifiable E/M Service), not the preventive visit code. The CPT code 99213 is the correct choice as the time spent on the date of the encounter falls in the range for 99213 (20- minutes). The 25 modifier represents a distinct service, over and above what is included in the procedure code (vaccine administration). If the problem visit E/M service had not been performed, modifier 25 would be appended to the Preventive visit (99395). The preventive counseling code (99401) was not used in this case because the service provided around immunizations is captured in the Preventive Visit code (99395), which includes patient specific counseling along with a patient specific history and exam and the option to order lab and diagnostic procedures. Some payors will not pay for two E/M codes during the same encounter. Practices should verify payer policy on E/M payment for two E/M services before reporting both services. The total time results in the same code as prior to the change in coding rules, though the method in which time is calculated is different. NB: If the patient accepted hepatitis B vaccination, then the additional codes would include:
Scenario Overview Patient Information : o Age : 30 years old. o Insurance : Private. o Existing patient : The patient has been seen by this provider before. Reason for Visit : Annual Preventive Visit (routine check-up). Request for Hepatitis B vaccination due to new employee requirements. Complaint of lower abdominal pain (new symptom requiring evaluation). What Happened During the Visit : o A comprehensive preventive exam was conducted. o Counseling was provided on: Hepatitis B vaccination (the patient ultimately declined the vaccine). Diabetes management (the patient is diabetic but stable). Age-appropriate screening labs and tests. o The patient complained of lower abdominal pain : A medically necessary evaluation and exam were performed for this issue. A diagnosis was made, and medication was prescribed. The physician spent 25 minutes addressing this specific problem. Key Coding Guidelines This visit involves two separately identifiable services:
- Preventive Visit : Annual check-up with counseling related to general health and immunizations.
Billing Codes Summary CPT Code Description 99395 Preventive visit for an established patient aged 18–39. Includes comprehensive exam and counseling. 99213- 25 Office visit for an established patient with low complexity. Modifier 25 indicates a separate E/M. Why Did the Total Time Not Change the Code Selection? The new coding rules allow non-face-to-face time (e.g., entering documentation) to count towards total time. However, the preventive visit code ( 99395 ) is not time-based ; it is determined by the patient’s age and the scope of the visit. The E/M code (99213) uses time as a factor, but the total time for the abdominal pain evaluation (25 minutes) naturally falls into the range for this code. Simplified Explanation The patient came in for a yearly check-up and also wanted to talk about getting a vaccine. During the visit, the patient complained of stomach pain, so the doctor did a separate check-up to figure out the problem and gave medicine to help. Because the doctor did two different things during the visit (the yearly check-up and a separate check-up for the stomach pain), the visit is billed with two codes:
- 99395 for the yearly check-up.
- 99213 for the stomach pain check-up, with a special note ( modifier 25 ) to show this was separate from the yearly exam. Even though the doctor spent time on both, the yearly check-up doesn’t use time to choose the code—it’s based on the patient’s age. The stomach pain check-up uses time, and 25 minutes matches the correct code. OFFICE VISIT: Vaccine counseling with shared clinical decision-making, vaccine administered A 28-year-old female is at her physician’s office for an asthma-related matter and to get a refill on birth control. She and her physician discuss the human papilloma virus (HPV) vaccine and reasons why she should complete the vaccination series. The patient has significant concerns about the vaccine, as she recently viewed a Facebook post about negative side effects. Vaccine counseling consumes a
large proportion of the visit. The patient receives the HPV vaccine. Her total visit time on the date of the encounter was 60 minutes. Explanation of code selection The correct billing for this service would include the CPT E/M office visit code 99215, with a time range of 40-54 minutes. In addition, because the total time on the date of the encounter was 60 minutes, a prolonged services code is appropriate. One unit of 99XXX (15 minutes) would be added to the base time of the 99215 code (i.e. 40 minutes). Therefore, at 60 total minutes, a prolonged services code 99XXX can be reported. A separate E/M service was provided in this situation in addition to the procedure, so modifier 25 would be appended to the E/M code (99215) because vaccine administration is considered a procedure. Since the vaccine was administered, the administration code (90471) and the vaccine code (90651) are billed. Because of new coding rules one unit (15 min) of a prolonged services code can be used. Office Visit and Time Spent What happened? The patient came to the office for two main reasons: to discuss asthma treatment and refill her birth control. During the visit, a lot of time was spent on vaccine counseling about the HPV vaccine, and she received the vaccine. Choosing the right office visit code: The office visit was coded as CPT 99215 because: o This code is used for a visit where the patient needs a high level of medical decision-making, OR o The visit takes a total of 40–54 minutes face-to-face with the provider. o Since the provider spent 60 minutes in total, a prolonged services code can be added for the extra time. Adding Prolonged Services Code
- 90651 : For the HPV vaccine itself.
- Modifier 25 : Added to 99215 to show that the office visit (counseling and asthma/birth control management) was separate from the procedure (vaccine administration). Why These Codes Were Chosen The office visit time and vaccine counseling justified the higher-level code (99215). The prolonged services code (99XXX) was added because the visit went over the time range for 99215. The vaccine codes (90471, 90651) and the modifier (25) ensured the vaccination part was properly documented and billed separately. OFFICE VISIT: Return visit for vaccination with series, with separately identifiable E/M The 28-year old female from Case 3 returns to her physician’s office 2 months later for the second of her series of three HPV vaccines. During the visit, she reports dysuria. A medically appropriate history and exam are completed. The physician orders a urinalysis. The urinalysis result shows a urinary tract infection (UTI). The physician prescribes antibiotics and provides counseling regarding prevention of future UTIs. Prior to leaving, the patient also receives her HPV vaccine. The physician enters documentation of clinical information into the electronic health record, including her immunizations. The physician’s total time on the date of the encounter was 30 minutes. 4As this is a new CPT code, the AMA will not issue the official CPT code number until the official CPT code license file is released on or near August 31, 2020. Explanation of code selection The correct E/M office visit is 99214, as the time on the date of the encounter falls within the appropriate time range (30-39 minutes). Since the vaccine was administered, the administration code (90471) and the vaccine code (90651) are
billed. A separate E/M service was provided in this situation in addition to the procedure, so modifier 25 would be appended to the E/M code. NB: If the patient comes back for the final HPV vaccine at the indicated time interval according to the ACIP guidelines (6 months after initial dose and 5 months after the second dose) and receives the vaccination as a nurse only visit with no counseling involved, this visit is coded as a vaccine only visit, as no E/M service was documented.
1. Office Visit (E/M) Code What happened? The patient came in for her second dose of the HPV vaccine and reported symptoms of dysuria (painful urination). This led the physician to: o Take a medically appropriate history. o Perform an exam. o Order and review a urinalysis, which confirmed a UTI. o Prescribe antibiotics and provide counseling for UTI prevention. Why use CPT 99214? o The physician spent 30 minutes on the encounter. The total time matches the time range for CPT 99214 (30–39 minutes). o This visit required more than vaccine administration. It included a detailed evaluation of the patient’s symptoms, a diagnosis of a UTI, and counseling. Why add Modifier 25? o The office visit (E/M) was separate from the vaccine administration. To show that the E/M service was distinct from the procedure, Modifier 25 is added to CPT 99214. 2. Vaccine Administration Code What happened? o The patient received the HPV vaccine.
complete sentences, reflecting proper spelling and grammar. Scenario 1 A patient presents to the Emergency Room following an incident in her home where she fell and hit her head on the edge of a table. She indicated she felt dizzy prior to the fall. The fall resulted in a 1.5 cm laceration to her forehead and another 0.75 cm laceration to her neck. In addition, she was experiencing a headache and some blurred vision. Note: In this scenario, the provider would need to evaluate the source of the dizziness and performed a simple repair the lacerations. Questions:
- Indicate the modifier that would be appended to the E/M code. You need to append a modifier to indicate that the evaluation and management (E/M) service was distinct from the procedure performed. Typically, this would be Modifier 25.
- Indicate the coding guideline applied to a simple repair of two lacerations, same site. According to CPT guidelines, when repairing multiple lacerations in the same anatomic site, you should sum the lengths of the lacerations and report a single repair code.
- Indicate the code for a Simple Repair of two lacerations to the forehead (scalp) and neck. For a simple repair of lacerations to the forehead (scalp) and neck, you would use the appropriate CPT code for simple repair based on the total length of the lacerations. Scenario 2 A patient is scheduled for an inpatient (hospital) surgical procedure. The patient was intubated, and anesthesia administered. The surgeon made the initial incision to access the operative site when the patient’s blood pressure dropped, and the patient became hypotensive. The procedure was aborted. Questions:
- Indicate the modifier that the surgeon would append to the surgical CPT code? The surgeon would append Modifier 53 to indicate a discontinued procedure.
- Indicate the modifier that would be appended to the surgical CPT code if this was an Outpatient Procedure? For an outpatient procedure, you would also use Modifier 53
- Under which circumstances would a “Discontinued Service” modifier not be allowable based on the definition? A “Discontinued Service” modifier is not allowable if the procedure was completed but not successful, or if the patient’s condition did not warrant discontinuation. Scenario 3 A patient is admitted for an emergency appendectomy due to a ruptured appendix with abscess. The patient is morbidly obese which presents difÏculty in removing the appendix and managing the operative site to avoid infection. Due to the obesity and complicated nature of the procedure, the procedure took 30 minutes longer than usual to perform the procedure and close the operative site. Questions:
- Which modifier would be appended to the appendectomy CPT code due to the increase in operative time? You would append Modifier 22 to indicate increased procedural services due to the complexity
- Which CPT format (punctuation) guides the coding pathway for determining the appropriate code for Ruptured Appendix? The CPT format uses specific punctuation and guidelines to determine the appropriate code. Refer to the CPT code book for detailed guidance
- What is the code for Appendectomy for a ruptured appendix with abscess?
CPT Code: ________. 99221 The patient is a 34-year-old established patient seen in the clinic by her dermatologist. She is followed for extensive psoriasis involving her scalp, trunk, and arms. It has now worsened and spread to her palms, and she is now also complaining of joint pain. The spread to her hands has made it difficult to do many of her day-to-day tasks. A detailed history and examination are performed. The examination includes inspection of the affected areas in addition to bending and rotation of joints. A long discussion took place regarding a change in her medications to try to gain better control of her psoriasis and slow down the systemic progression. Topical and systemic treatment was decided on. CPT Code: ________. 99214 The patient is a 52-year-old male from out of state visiting his daughter. He left his medications for his benign hypertension at home and is now here in the clinic in need of a prescription. A problem focused history and examination is performed and a prescription is given to the patient. CPT Code: ________. 99201 A 38-year-old female has severe low back pain due to a trauma injury she experienced as a factory worker 4 years ago. The chronic pain has become almost unbearable, and her internal medicine physician cannot go any further with her treatment. An initial outpatient consultation is requested and the patient is sent to see the pain management specialist for suggestions to control the chronic pain. A comprehensive history is taken, including all of the pertinent information regarding her injury. During the comprehensive examination the patient's gait and movement were observed. Moderate-complexity decision making is performed, including different treatment options. A separate note is dictated to show the requesting
physician what results were found during the visit, and the decision on treatment of her pain. CPT Code: ________. 99244 A 46-year-old male is admitted to the hospital with a progressive staphylococcal pneumonia that is not responding to treatment. A request is made for the infectious disease physician on staff to render his opinion for treatment. The patient is seen in initial inpatient consultation. An expanded problem focused history and examination are performed. After looking at the sputum cultures, the physician decides on the most effective antibiotic for treatment. The decision making is straightforward. CPT Code: ________. 99252 A 44-year-old patient, with chronic mastoiditis, was seen in consultation by the ENT specialist in the office. Her physician was inquiring as to the advantages of surgery versus continued antibiotic treatment when an acute flare comes on. The ENT specialist recommends surgery because of the increasing severity with each acute flare. She is fearful of the surgery because of the need to go under general anesthetic and a fear of permanent hearing loss. The physician performs an expanded problem focused history to include the duration of this problem and how many acute flares a year the patient experiences. An expanded problem focused examination and straightforward decision making is completed. It is determined that with the number of acute flares a year and the increasing severity of each case that surgery is recommended. The patient's fears are laid to rest and the patient decides to go ahead with the surgery. CPT Code: ________. 99242
CPT Code: ________. 99285 An 88-year-old female's family physician comes to the nursing facility to perform the resident's annual assessment. A detailed interval history is taken with some information from the patient, but because of her limited cognitive abilities, most of the information is gathered from the nurses and past records. A comprehensive multisystem physical examination is performed, which includes extensive body areas and related organ systems. The MDM complexity was moderate because multiple diagnoses must be considered for this patient, who has senile dementia, diabetes, hypertension, hypothyroidism, and recurrent transient ischemic attacks. The creation of a new treatment plan is required because some of the patient's conditions have worsened. CPT Code: ________. 99318 Subsequent follow-up care is provided for the 82-year-old male nursing facility patient with Alzheimer's disease. The resident has responded well to some new medications and appears to have recovered some of his cognitive abilities without behavioral disturbances. The physician performs a problem focused history and physical examination on his neurological problem and orders the current treatments continued. The MDM complexity is low. CPT Code: ________. 99307 The physician provides services to a resident of a rest home for an ulcerative sore on the heel and midfoot. Given the fact that the patient is in reasonably good health and is not diabetic, the physician focuses his attention on the right lower extremity during the problem focused physical examination. The physician knows the resident well and performs a brief HPI and ROS during a problem focused history. The resident thinks the sore is from new shoes, and the physician agrees with that
conclusion. Topical antibiotic cream is ordered, and the new shoes are sent to be stretched. The MDM complexity is straightforward. CPT Code: ________. 99334 An established patient is seen in the office for a new problem that requires a comprehensive history and examination. The MDM complexity is high, and the physician spends 40 minutes with the patient. However, the patient has numerous concerns, and the physician spends an additional hour and 50 minutes in prolonged direct patient contact. CPT Codes: ________. 99215 for the office visit (Office and/or Other Outpatient Services, Established Patient) and 99354 and 99355_2 for the Prolonged Services (Prolonged Services). 99215 is for the 40 minutes of initial office service, and 99354 and 99355 are for the additional 110 minutes. A 64-year-old man arrives at his appointment with his family physician for his annual physical examination. The patient has no new complaints and all of his medications remain the same. He is told to follow up in 1 year or sooner if necessary. CPT Code: ________. 99396 A new patient is seen in the office complaining of a sore throat and reports a low- grade fever for the past 4 days. The physician performs an expanded problem focused history and an expanded problem focused examination of the respiratory and lymphatic system. The physician's impression was pharyngitis and straightforward decision making was performed. Amoxicillin was prescribed.
