What is a 99213 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 99213 is the specific code for an established  Level 3 patient and is commonly overused by practitioners. The reason for the low use of this level of service is due to the risk the patient presents with is typically much higher than the low risk required for a 99213 level of service.  Also, for an established patient visit, most practitioners will complete a more history and exam than the minimum needed for this level of service.

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For an 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., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/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

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

  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 99213 the following items must be met for any combination of two out of three components.

  1. History – one element of HPI, two systems reviewed, and no PMFSH

  2. Exam- Minimum of two systems and a maximum of seven systems

  3. Low-risk complaint and needs to have either two diagnoses, two treatment option or two data reviews.

Example

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

ROS – Ear, nose throat - positive for nasal congestion
 

Exam – General – well developed well-nourished
 

               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 99213.

The other option for billing for evaluation and management codes is the unit of time.  For a 99213 the practitioner must spend at least 15 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.