HNS Policy 

 

The most appropriate level of E/M code should be reported to HNS contracted payors and documentation must clearly support the level of E/M service billed.

 

All E/M services reported to a HNS contracted payor must be medically necessary, properly documented in the patient’s healthcare record and must be consistent with the chief complaint/clinical findings, diagnoses and treatment plan.

 

            Report of Findings

               Report of Finding visits are included in the E/M code  billed.

               Report of findings cannot be billed as a separate visit.

 

Consultation E/M Codes: Consultation codes may ONLY be billed when another physician, insurer, employer, or other appropriate source has requested your opinion or advice. 

 

If such a consultation has been requested:

  • The verbal or written request must be clearly documented in the patient's healthcare record including the name of the provider or organization requesting the advice or opinion and the date it was received. 

  • The provider's written report to the requesting physician or appropriate organization, including his opinion, advice and/or any services ordered or performed, must be clearly documented in the patient's healthcare record. A copy of this report must be maintained in the patient's healthcare record.

 

 

 

E/M Services – New Patient 

 

A new patient is one who has not received any professional services from the provider (or another chiropractor in the same group practice) within the past three years.

 

NOTE: The provider may need to indicate, by CPT code, that on the day a procedure or service was performed, the patient’s condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual pre-service and post-service care associated with the procedure that was performed.  This should be reported by adding modifier -25 to the appropriate level of E/M service.

 


Requirements for level of E/M services – New Patient

 

99201 – Brief

 

Requires these 3 key components

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

Usually, the presenting problems are self-limited or minor. Providers typically spend 10 minutes face-to-face with the patient or family.

 

 

99202 – Limited

 

Requires these 3 key components

  1. Expanded problem focused history

  2. Expanded problem focused examination

  3. Straightforward medical decision making

Usually, the presenting problems are of low to moderate severity. Providers typically spend 20 minutes face-to-face with the patient or family.

 

 

99203 – Intermediate

 

Requires these 3 key components

  1. Detailed history

  2. Detailed examination

  3. Medical decision making of low complexity

Usually, the presenting problems are of moderate severity. Providers typically spend 30 minutes face-to-face with the patient or family.

 

 

* 99204 – Extensive

 

Requires these 3 key components

  1. A comprehensive history

  2. A comprehensive examination

  3. Decision making of moderate complexity (indicates a moderate degree of mortality without treatment)

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

Usually, the presenting problems are of moderate to high severity. Providers typically spend 45 minutes face-to-face with the patient or family.

 

 

*99205 Comprehensive

 

Requires these 3 key components

  1. A comprehensive history

  2. A comprehensive examination

  3. Decision making of high complexity (indicates a high degree of mortality without treatment)

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

Usually, the presenting problems are of moderate to high severity. Providers typically spend 60 minutes face-to-face with the patient or family.

 

 

 

E/M Services – Established Patient

 

An established patient is one who has received professional services from the provider (or another chiropractor in the same group practice) within the past three years.

 

NOTE: The provider may need to indicate, by CPT code, that on the day a procedure or service was performed, the patient’s condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual pre-service and post-service care associated with the procedure that was performed.  This should be reported by adding modifier -25 to the appropriate level of E/M service.

 

To determine the appropriateness of further care, E/M services should be performed approximately every 4 weeks or every 12 visits (whichever comes first) unless in between the 4 week/12 visit protocol, there has been significant change to warrant re-examination that results in a change to the treatment plan.

 

 

Requirements for level of E/M services – Established Patient

 

99211 – Brief

 

Office visit for the evaluation and management of an established patient.  Usually the presenting problems are minimal.

 

Requires these 3 key components

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

Usually, the presenting problems are minimal. Providers typically spend 5 minutes performing or supervising these services.

 

 

99212 – Limited

 

Requires at least 2 of these 3 key components

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

Usually, the presenting problems are self limited or minor. Providers typically spend 10 minutes face-to-face with the patient or family.

 

 

99213 – Intermediate

 

Requires at least 2 of these 3 key components

  1. Expanded problem focused history

  2. Expanded problem focused examination

  3. Medical decision making of low complexity

Usually, the presenting problems are of low or moderate severity. Providers typically spend 15 minutes face-to-face with the patient or family.

 

 

*99214 – Extensive

 

Requires at least 2 of these 3 key components

  1. A detailed history

  2. A detailed examination

  3. Medical decision making of moderate complexity (indicates a moderate degree of mortality without treatment)

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

Usually, the presenting problems are of moderate to high severity. Providers typically spend 25 minutes face-to-face with the patient or family.

 

 

*99215 – Comprehensive

 

Requires at least 2 of these 3 key components

  1. A comprehensive history

  2. A comprehensive examination

  3. Decision making of high complexity (indicates a high degree of mortality without treatment)

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

Usually, the presenting problems are of moderate to high severity. Providers typically spend 40 minutes face-to-face with the patient or family.

 

 

 

E/M Services - Consultations

 

A consultation initiated by a patient and/or family and not requested by a physician or other appropriate source should not be reported using an E/M consultation code. 

 

NOTE: The provider may need to indicate, by CPT code, that on the day a procedure or service was performed, the patient’s condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual pre-service and post-service care associated with the procedure that was performed.  This should be reported by adding modifier -25 to the appropriate level of E/M service.

 

NOTE:  “Report of Findings” visits do not meet the requirements of an E/M Consultation so providers should not report their standard "Report of Findings” visits using an E/M CPT code.

 

HNS has provided a sample "Consultation Form"we recommend you use if billing for consults. This form is available on this website under the tab "HNS Forms" in Microsoft Word format.

 

 

Requirements for level of E/M services – Consultations

 

99241

 

Requires these 3 key components

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

Usually, the presenting problems are self-limited or minor. Providers typically spend 15 minutes face-to-face with the patient or family.

 

 

99242

 

Requires these 3 key components

  1. Expanded problem focused history

  2. Expanded problem focused examination

  3. Straightforward medical decision making

Usually, the presenting problems are of low severity. Providers typically spend 30 minutes face-to-face with the patient or family.

 

 

99243

 

Requires these 3 key components

  1. Detailed history

  2. Detailed examination

  3. Medical decision making of low complexity 

Usually, the presenting problems are of moderate severity. Providers typically spend 40 minutes face-to-face with the patient or family.

 

 

*99244

 

Requires these 3 key components

  1. A comprehensive history

  2. A comprehensive examination

  3. Decision making of moderate complexity (indicates a moderate degree of mortality without treatment)

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

Usually, the presenting problems are of moderate to high severity. Providers typically spend 60 minutes face-to-face with the patient or family.

 

 

*99245

 

Requires these 3 key components

  1. A comprehensive history

  2. A comprehensive examination

  3. Decision making of high complexity (indicates a high degree of mortality without treatment)

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

Usually, the presenting problems are of moderate to high severity. Providers typically spend 80 minutes face-to-face with the patient or family.

 

 

 

The following chart is provided to assist you with choosing the correct level of E/M service

EM choices chart