EVALUATION AND MANAGEMENT CODES

The E/M section of the CPT coding book describes patient encounters with the physician for all services other than procedures and miscellaneous services. The E/M services can be either problem-oriented or preventive in nature. The CPT book divides the E/M codes into multiple categories: office or other outpatient services; hospital observation; hospital inpatient services; consultations; emergency department services; critical care; nursing facilities − initial and subsequent; discharge; rest home; home services; prolonged services; case management; care plan oversight; preventive and special evaluation and management. The appropriate code selection from this section is dependent on the place of service for the patient and the type of service. The most common services used in the allergist office are outpatient services, consultations and, occasionally, inpatient hospital services. Many of the codes in this section of the book have a time component associated with the code. The time component is not applicable, however, for selection of the code unless the encounter is >50% counseling and coordination of care. In these instances, the time component of the code is used to determine the appropriate level of service.

Office or Other Outpatient Service Codes

The new patient codes(99201-99205) are forservices provided in the office and other outpatient facilities to evaluate a patient who is new to the practice. The CPT definition of a new patient vs. an established patient is a patient who has not received any faceto-face professional services by the physician or by another physician of the exact same specialty and subspecialty of the same group practice in the past three years. An established patient (codes 99211- 99215) is one who has ongoing services provided by the physician or any physician of the exact same specialty and subspecialty in the same group practice. If a physician is covering for another physician, the patient encounters will be considered as if the absent physician were treating the patient. The only setting in which there is no difference in new or established patients is in the emergency setting. The established patient encounter (code 99211, nurse visit) does not require a physician to see the patient. However, it requires a chief complaint and it requires the physician to be in the suite to support the “incident to” guidelines set for supervision of physician staff.

Inpatient Hospital Service Codes

Hospital services are not differentiated according to whether the patient seeing the physician is a new patient or an established patient. Hospital services codes differentiate between the services during the initial encounter while the patient is admitted to the hospital and the subsequent care of the patient while in the hospital for that encounter. The codes for initial encounters (99221-99223) are for the initial workup to place the patient in the hospital for care. The subsequent care codes (99231-99233) are for those services provided on a daily basis by the admitting physician and by any consulting physicians while the patient is hospitalized for the course of his/her illness. These codes are based on the patient history and exam and medical decision-making. Time is used to determine only the level of code if >50% of the encounter was counseling and coordination of care for the patient. If the CPT code is going to be determined by counseling and coordination of care, the counseling and coordination of care for the patient must be done by the physician, not the staff.