What is it, who can bill for it and who will reimburse it?
Both of these Current Procedural Terminology (CPT) Codes belong to a set of codes (99211-99215) used for billing. They are all part of HCPS, the Healthcare Common Procedure Coding System. These codes can be used to bill for established patients who are being treated in an office environment for both or either medical or mental health conditions.
Some healthcare providers may find it a bit difficult to decide when to bill for these two codes. CPT Codes 99212 and 99213 may be part of this same family of codes, but the regulations that need to be followed for reimbursement are very different. One code requires more time with the patient than the other, so it is very important to know which code to use for billing. This also ensures that clinicians who are billing with either of these codes will be reimbursed fully.
Some providers bill for CPT Code 99212, when they could actually be billing with the higher reimbursable CPT Code 99213. To be sure that the billing code corresponds correctly with the office visit, let’s look a bit closer at the details and regulations associated with each code.
What exactly are CPT Codes 99212 and 99213?
(Change to 99212) CPT Code 99212 can be billed for the third highest level in care during the patient’s visit. CPT Code 99212 is a level two code. It must be billed with an established patient, not as a new patient visit of any form. The visit should be conducted in an outpatient atmosphere or as an in-office visit. Though the revenue for this code is not as high as with CPT Codes 99213 and 99214, it is widely used, especially as that it does not require a review of systems (ROS). Since the inclusion of mental healthcare in the Affordable Care Act in 2013, attention has been drawn to this code and those within the same family of codes for reimbursements.
For CPT Code 992213, an outpatient or inpatient office visit that is considered to be a mid-level visit can be billed with this code. CPT Code 99213 can only be used for an already established patient. It is a level 3 code. The patient must have a medical history. Yet, it should be no surprise to see that this code is very popular. In fact, among middle-level billing codes, it is the second most used. Many clinicians find that they are more successful when billing with this code than with some of the higher-level codes.
Who can bill with CPT Codes 99212 and 99213?
CPT Codes 99212 and 99213 can used for billing by all sorts of medical professionals who are wanting to assess a patient’s behavior. But keep in mind that even though it is commonly used for behavioral assessments, it is used by a larger variation of clinicians than just therapists or psychiatrists. Behavioral health assessments can be utilized in a large number of healthcare environments, most commonly by primary care physicians.
When you think of a primary care doctor using CPT Code 99212, let’s look at a simple scenario. A patient with existing history has an office visit for a routine health examination for a prescription refill for chronic pain. Often, when patients are experiencing chronic pain, they may also have feelings associated with depression. In this case, standardized assessment tools for depression (e.g. PHQ-9) may be used by the physician to gain more information. This can help determine if the patient that can be prescribed by the physician. Or, perhaps a referral is in order.
An example of a physician billing with CPT Code 99213 could be an existing patient that has scheduled an appointment for neck pain. Maybe has been occurring for several years. The patient could possibly be using anti-inflammatories and muscle relaxants. The patient may also be treating anxiety associated with this pain with a low-dose anxiolytic medication. During this visit, there are no new medications prescribed for any other ailments, and the diagnosis remains the same. In this case, behavioral assessment tools may be used by the physician to make sure that the anxiety levels have not worsened since the previous visit.
What procedures are there for billing CPT Codes 99212 and 99213?
It is very important to understand the regulations for billing with CPT Code 99212. Two out of the three factors below must be present if the clinician hopes to bill with CPT Code 99212. These required components should include:
- A problem-focused interval medical history
- A problem-focused exam
- Medical decision-making that is very simplified and straightforward
Two out of three of these components are a requirement when billing necessary for CPT Code 99212. Plus, the face-to-face time spent with the patient must total at least 10 minutes. The reasons for the medical visit are usually of a mild complexity.
When using CPT Code 99213, it is also equally as important to understand the necessary components for billing. However, it is required to have two out of three of the these components:
- An expanded history that is problem focused
- An expanded exam that is problem focused
- Medical decision-making that is considered to be of a low complexity
Any two of these three components will allow a clinician to use CPT Code 99213 for billing. However, there must also be a total of 15 minutes of face-to-face time experienced with the patient during the visit. The reasons for the visit must be considered low to moderate in severity.
Most clinicians easily recognize what is required for the detailed or expanded exams. However, the history and decision-making requirements are not always achieved so easily. Yet, adhering to the requirements and documenting along the way can be very simple, as long as the stipulations are followed.
For example, the detailed or expanded history can be documented simply by viewing the charts of the existing patient in question. Another easy way to gather this information is through assessments. Using mental health assessment tools during the visit to reveal underlying causes for a health condition is an excellent method.
The decision making process can include a consultation with a specialist (e.g. a psychologist or a psychiatrist). It can also include deciding whether to carry on with an existing prescription plan.
How often can testing be billed with CPT Codes 99212 and 99213?
When the complexity of the visit is discovered, the healthcare professional may then move forward with an examination that can be reimbursed through the appropriate billing codes. CPT Codes 99212 and 99213 may be billed for each patient during each session in accordance with the time spent, as long as the regulations for billing requirements are met. What this means for healthcare providers is that not only will they be able to bill for behavioral assessments, but they will be able to offer a level of mental healthcare to patients who may not be receiving this elsewhere.
How much are reimbursements for screenings billed using CPT Codes 99212 and 99213?
When billing with CPT Codes 99212 and 99213, the monetary amounts for billing are based primarily on the actual time that is spent with the patient during the visit. This will also include the use of behavioral assessment tools. Let’s look at a major national healthcare insurer’s policies, which allows CPT Code 99212 to be reimbursed up to $43.10 for each patient. With the same insurer, CPT Code 99213 can be reimbursed up to $72.70 for each patient. That is a difference of nearly $30 for each patient billing under CPT Codes 99212 and 99213. Can you see how that can add up quickly?
Where can I find standardized screening instruments to use with CPT Codes 99212 or 99213 for behavioral assessments?
Mentegram has a library full of online tools, such as the PHQ-9. These tools can range from simple surveys to more-detailed questionnaires. Plus, they can even be administered on a tablet in the waiting room. However, using these tools can be used to increase the complexity level of the patient’s visit. In turn, it will allow the clinician to bill for the appointment using a higher code (e.g. billing CPT Code 99213 instead of 99212). Furthermore, these tools can even be used to reduce and even replace paperwork. This can save extremely valuable time in not only assessing the patient for behavioral health, but in patient intake and monitoring between office visits.
What are the most important things to remember about differentiating between CPT Codes 99212 and 99213?
- Above all else, be certain to adhere to the difference in the components for each code that must be present to allow for billing that specific code.
- Ensure that medical necessity is the reason behind changing the complexity of the office visit.
- Make sure that all documentation is supported by the level of care that the clinician is billing for.
Don’t hesitate to ask us how you can start billing with CPT Codes 99212 and 99213, along with a variety of other codes!
Would you like more information on how to to bill with other codes and increase your practice’s revenue? Be sure to read our articles on CPT Code 96103, CPT Code 96127 and a comparison between CPT Codes 99213 and 99214:
DISCLAIMER: Please keep in mind that Mentegram is a healthcare technology company, and do not consider content on our website as legal advice. It is your responsibility to decide to act on this content, relinquishing Mentegram of all claims. The information that we share is based on what has been effective for our customers and the best practices as published by authoritative sources.
For specifics regarding your individual practice and specific cases, please consult the particular insurance companies or your office’s billing consultant for additional information.