What is a 99212 for E and M coding?

For a physician, nurse practitioner or physician assistant to be compensated for the services they provide to a patient they must correctly document the events that occurred in the room.  While most medical practitioners document the items, they feel are pertinent, however, CMS has specific criteria that must be documented for each level of service.

The E and M code 99212 is the specific code for an established patient Level 2 patient and is used less often than higher codes such as 99213 and 99214.   The biggest reason for the low use of this level of service is simply due to the fact that patients typically do not come to the doctor for the types of complaints that qualify for a minimal risk complaint.  These complaints are most often items such as, insect bites, common colds, dandruff or other simple complaints that resolve themselves or are easily treated with OTC options.

The items needed to code for this Level of service is made up of the 3 components of the progress note.  For established patient 2 out of 3 components must be met.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality, and timing

  2. Past medical family and social history

  3.  Review of Systems – 14 recognized systems

  •  Constitutional (e.g., vital signs, general appearance)

  •  Eyes

  •  Ears, nose, mouth, and throat 

  •  Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  • Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

2.) Exam- The physical exam component is comprised of  

  • Constitutional (e.g., vital signs, general appearance)

  • Eyes

  • Ears, nose, mouth and throat 

  • Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  • Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3. Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For an established patient 99212 the following items must be met for any combination of two out of three components.

  • History – one element of HPI, no system reviewed, and no PMFSH

  • Exam- Minimum of one system examined.

  • minimal risk complaint and needs to have either one diagnosis, one treatment option or one data review.

Example:

27 yo male here for a complaint of seasonal allergies and has used OTC Flonase with mild relief.

Exam – ENT – clear nasal discharge noted

Diagnosis – Seasonal allergies

As you can see from the above example it does not take much documentation to bill for a 99212.

The other option for billing for Evaluation and management codes is the unit of time.  For a 99212 the practitioner must spend at least 10 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All of these components should be documented.