Why to Use the Established Patient Code 99214 Versus 99213?

Research shows that 61% of Doctors use 99213 to bill for an Established Patient Visit. Many Doctors may be down coding when the visit could justify a higher-level code. CPT Code 99213 is used normally when a patient is not sick and is relatively healthy. For example, a patient cuts his arm but if a patient has an immune disorder or the cut is infected it would be better to bill with a higher-level code.

When you decide it's necessary to code at a higher-level it's important to be mindful of the time you have spent with the patient. Also it does well to keep in mind anything that has moved the focus to another initial complaint can also call for a higher-level code such as 99214. It's important that when a Doctor decides to use a higher-level code, they need to make sure to document, document, document! Good chart notes by a Doctor will help to back up the usage of a higher-level code if it has been denied by the Insurance Company. If the patient has discussed with the Doctor more than one problem, it would be appropriate to add all the diagnosis codes to the claim to meet the criteria for billing at that higher-level code.

A suggestion used by other Doctors for tracking the time spent with a patient would be to have a clock in each exam room and when the Doctor begins their exam, they would write down the time the exam begins and ends on the back of the Superbill. If the Doctor decides that they need to consult with another Doctor regarding their patient, while the patient is still in their office, this time too should be tracked. Writing the time on the back of the Superbill is so the patient does not see the Doctor looking at their watch, which could make the patient feel they are in a hurry and also the patient will most likely never see the time written on the back.

Doctors do well to talk with their Insurance Biller and Staff to let them know that they would like to implement this practice. The majority of Insurance Billers are in an office away from the hands-on patient care that's taking place in the office or the Doctor is using an off-site billing service. Communication with the Insurance Biller, Front Office, Nurses or Back Office Assistants is very important to implement any new practice within the office. A Medical Office that has good communication and cooperation have such a profound affect on any Medical Practice.

Doctors may be hesitant to change from billing 99213 to 99214 for office visits but when they sit down and calculate the time spent, they most likely will recognize they have been giving away hours of their day for free.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full "Interview with Marina Hall" visit her website at http://www.inscoding.com/aboutus.php

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