Cracking the (CPT) Code: How to Assign an Office Visit Code

Last week, I discussed the elements involved in selecting the appropriate office visit CPT code. Today, I'll bring these pieces together to look at just how final office visit code selection is made. While the formula for selecting the appropriate CPT code is relatively straightforward, the process of coding efficiently takes time and understanding to master. Here's what you need to know to crack the office visit CPT coding process.

To review, the first step to assigning CPT codes accurately is to identify the components that must be considered in code assignment. The four components taken into account are: 

  1. New vs. established patient
  2. Level of history
  3. Level of physical exam
  4. Level of medical decision making

Each of these components is then divided into subcategories. Subcategories help determine the level of complexity of the history, exam, and medical decision making involved in the patient encounter. Evaluating each subcategory allows the provider to assign a designation to the level of complexity of each of the four components. The following tables outline the requirements for designating the level of complexity of each component. 

New vs. established patient

  • Established - patient has received services from the provider or another provider in the same group within the past three years
  • New - patient has not received services from the provider or another provider in the same group within the past three years

Level of History

  • History of present illness (HPI)
  • Review of systems (ROS)
  • Past, family, and social history (PFSH) 

Level of physical exam

  • Number of body areas and/or organ systems assessed

Level of medical decision making

  • Options for diagnosis and management
  • Amount and/or complexity of data reviewed
  • Risk of complications or comorbidities

Bringing It All Together

Once a designation has been assigned to each of the four components, the appropriate office visit CPT code may be selected. The following tables guide code selection based on whether the patient is new or established.

For new patients, all three key components in the row must meet or exceed the requirements for a given level of service. For example, a patient visit for which a detailed history and physical exam is documented along with a low complexity of medical decision making would be assigned a 99203 office visit code. A patient visit for which a detailed history, an expanded-problem focused exam, and a low complexity of medical decision making, would be assigned the code 99202. The visit does not qualify for a 99203 code as the exam complexity does not meet the 99203 code requirement. 

For established patients, two of the three components in each row must meet or exceed the requirements for a given level of service. For example, a patient visit for which a detailed history and physical exam is documented along with a moderate complexity of medical decision making would be coded as a 99214 office visit. A patient visit for which a detailed history, a detailed exam, and a low complexity of medical decision making, is documented would also receive the code 99214 as two of the three components meet the requirement for the level of service. 

CPT coding guidelines may seem complex, however by devoting a little time to understanding the process, nurse practitioners can crack CPT office visit coding. 

 

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