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Coding for Medical Home Visits

Updated 1/1/2016

 

Index of Current Procedural Terminology (CPT) Codes for Medical Home

The following index was originally published in November 2003 in Medical Home Crosswalk To Reimbursement. The information was developed by Margaret McManus, Alan Kohrt, Joel Bradley, and Linda Walsh in collaboration with the Center for Medical Home Improvement, the American Academy of Pediatrics, and the National Institute for Children’s Healthcare Quality. Funded by the Maternal and Child Health Bureau, U.S. Department of Health and Human Services through the Maternal and Child Health Policy Research Center.

Codes Services and Description
Physician Evaluation and Management Services; Face-to-Face
Outpatient
99201 Office or other outpatient visit, new* patient; self limited or minor problem, 10 min.
99202 ​     low to moderate severity problem, 20 min.
99203 ​     moderate severity problem, 30 min.
99204 ​     moderate to high severity problem, 45 min.
99205 ​     high severity problem, 60 min.
99211 Office or other outpatient visit, established patient; minimal problem, 5 min.
99212 ​     self limited or minor problem, 10 min.
99213 ​     low to moderate severity problem, 15 min.
99214      moderate severity problem, 25 min.
99215 ​     moderate to high severity problem, 40 min.
99241 Office or other outpatient consultation, new or established patient; self-limited or minor problem, 15 min.
99242 ​     low severity problem, 30 min.
99243 ​     moderate severity problem, 45 min.
99244 ​     moderate to high severity problem, 60 min.
99245 ​     moderate to high severity problem, 80 min.
​NOTE: Use of these codes requires the following:
a) Written or verbal request for consultation is documented in the patient chart;
b) Consultant’s opinion as well as any services ordered or performed are documented in the patient chart; and
c) Consultant’s opinion and any services that are performed are prepared in a written report, which is sent to the requesting physician or other appropriate source (Note: Patients/Parents may not initiate a consultation)
d)For more information on consultation code changes for 2010 see the AAP Position Paper.
99341 Home visit, new* patient; low severity problem, 20 min.
99342 ​     moderate severity problem, 30 min.
99343 ​     moderate to high severity problem, 45 min.
99344 ​     high severity problem, 60 min.
99345 ​     patient unstable or significant new problem requiring immediate attention, 75 min.
99347 Home visit, established patient; self-limited or minor problem, 15 min.
99348 ​     low to moderate problem, 25 min.
99349 ​     moderate to high problem, 40 min.
99350 ​     patient unstable or significant new problem requiring immediate attention, 60 min.
+99354 Prolonged services in office or other outpatient setting, with direct patient contact; first hour (use in conjunction with time-based codes 99201-99215, 99241-99245, 99301-99350)
+99355 ​     each additional 30 min. (use in conjunction with 99354)
Preventive Medicine Services
99381 Initial comprehensive preventive medicine, new* patient; infant under 1
99382 ​     ages 1-4
99383 ​     ages 5-11
99384 ​     ages 12-17
99385 ​     ages 18-39
99391 Periodic comprehensive preventive medicine, established patient; infant under 1
99392 ​     ages 1-4
99393 ​     ages 5-11
99394 ​     ages 12-17
99395 ​     ages 18-39
99401

Preventive medicine counseling and/or risk factor reduction provided to an individual and should address issues such as family problems, diet and exercise, substance abuse, injury prevention, and diagnostic and lab results; 15 min.

Not for reporting counseling or risk factor reduction provided to patients with symptoms or established illnesses.

99402 ​     30 min
99403 ​     45 min
99404 ​     60 min
99420 Administration and interpretation of health risk assessment instrument
Group Setting
99411 Preventive medicine counseling and/or risk factor reduction provided to individuals in a group setting; 30 min.
99412 ​     60 min.
99078 Physician educational services rendered to patients in a group setting (eg, obesity or diabetic instructions)
Disability E/M services
99450 Basic life and/or disability evaluation services that includes measurement of height, weight, and blood pressure, completion of a medical history following a life insurance pro forma, collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and completion of necessary documentation/certificates.
99455 Work related or medical disability evaluation services that include completion of medical history commensurate with patient's condition; performance of examination commensurate with patient's condition; formulation of diagnosis; assess of capabilities and stability and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report.
Inpatient and Observation
​99218 ​Initial observation care, per day, patient is admitted to “observation status”  due to problem(s) of low severity. 30 min.
​99219      ​patient is admitted to “observation status” due to problems of moderate severity, 50 min.
​99220 ​     patient is admitted to “observation status” due to problems of high severity, 70 min.
​99224 Subsequent observation care, per day, patient is stable, recovering or improving, 15 min
​99225 ​     patient is responding inadequately to therapy or has developed minor complication, 25 min.
​99226 ​     patient is unstable or has developed a significant complication or new problem, 35 min.
​99217 Observation care discharge
​99221 Initial hospital care, per day, patient is admitted due to a problem(s) of low severity, 30 min.
​99222 ​     patient is admitted due to a problem(s) of moderate severity, 50 min.
​99223 ​     patient is admitted due to a problem(s) of high severity, 70 min.
​99231 Subsequent hospital care, per day, also used for follow-up inpatient consultation services; patient is stable, recovering or improving, 15 min.
​99232 ​     patient is responding inadequately to therapy or has developed minor complication, 25 min.
​99233 ​     patient is unstable or has developed a significant complication or new problem, 35 min.
99238 Hospital discharge day management; 30 min. ​
99239 ​     more than 30 min
99251 Initial inpatient consultation, new or established patient; self-limited or minor problem, 20 min.
99252 ​     low severity problem, 40 min.
99253 ​     moderate severity problem, 55 min.
99254 ​     moderate to high severity problem, 80 min.
​99255 ​     moderate to hign severity problem, 110 min.
NOTE: Refer to codes 99241-99245 for more details on the use of these codes.
+99356 Prolonged physician services in the inpatient setting; first hour (use in conjunction with time-based codes 99221-99233, 99251-99255)
​+99357 ​each additional 30 min. (use in conjunction with 99356)
Reporting E/M services using "Time"
  • When counseling or coordination of care dominates (ie, more than 50%) the physicians/patients or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. 
  • This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record. 
  • For coding purpose, face-to-ace time for these services is defined as only that time that the physician spends face-to-face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient. 
  • When codes are ranked in sequential typical times (such as for the office-based E/M services or consulation codes) and the actual time is between 2 typical times, the code with the typical time closest to the actual time is used. 
  • Prolonged services can only be added to codes with listed typical times such as the ones listed above. In order to report physician or other qualified health care professionalprolonged services the reporting provider must spend a minimum of 30 minutes beyond the typical time listed in the code level being reported. When reporting outpatient prolonged services only count face-to-face time with the reporting provider. When reporting inpatient or observation prolonged services you can count face-to-face time, as well as unit/floor time spent on the patient's care. However, if the reporting provider is reporting their services based on time (ie, counseling/coordinating care dominate) and not key components, then prolonged services cannot be reported unless the provider reaches 30 minutes beyond the listed typical time in the highest code in the set (eg, 99205, 99226, 99223). It is important that time is clearly noted in the patient's chart. For reporting of clinical staff prolonged services refer to codes 99415-99416 below. 
Physician Non-Face-to-Face Services
99339 ​Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
99340 ​30 minutes or more
+99358 Prolonged physician services without direct patient contact; first hour. NOTE: This code is no longer an “add-on” service and can be reported alone.
​+99359 ​     each additional 30 min. (+ designated add-on code, use in conjunction with 99358)
99367 Medical team conference by physician with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more
99374 Care plan oversight services requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports and related lab studies, communications, integration of new information into treatment plan, and/or adjustment of medical therapy, patient under care of home health agency, 15-29 min.
99375 ​     Same, 30 min. or more
99377 ​Care plan oversight services, patient under care of hospice, 15-29 min.
99378 ​     Same, 30 min. or more
99379 ​Care plan oversight, patient in a nursing facility, 15-29 min.
99380 ​     Same, 30 min. or more
99441 Telephone evaluation and management to patient, parent or guardian not originating from a related E/M service within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
99442 ​     11-20 minutes of medical discussion
99443 ​     21-30 minutes of medical discussion
99444 Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, no originating from a related E/M service provided within the previous 7 days, using the internet or similar electronic communications network
​99487 ​Complex chronic care coordination (C4) services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month
​99488 ​first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month
​99489

​each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

 

​C4 services are reported by the physician or qualified health care professional who provides or oversees the management and coordination of all of the medical, psychosocial, and daily living needs of a patient with a chronic medical condition. Typical pediatric patients
  1. receive three or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy)
  2. have two or more chronic continuous or episodic health conditions expected to last at least 12 months (or until death of the patient) and places the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.
  3. commonly require the coordination of a number of specialties and services.

​C4 service codes are selected based on the amount of time spent by clinical staff providing care coordination activities and whether or not the patient had a face-to-face encounter with the reporting physician or other qualified health care professional during the reporting period. CPT clearly defines what is defined as care coordination activities. In order for a practice/office to report C4 codes, it must

  1. provide 24/7 access to physicians or other qualified health care professionals or clinical staff;
  2. use a standardized methodology to identify patients who require chronic complex care coordination services
  3. have an internal care coordination process/function whereby a patient identified as meeting the requirements for these  services starts receiving then in a timely manner
  4. use a form and format in the medical record that is standardized within the practice
  5. be able to engage and educate patients and caregivers as well as coordinate care among all service professionals, as appropriate for each patient.

99495 ​    Transitional care management (TCM) services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision-making of at least moderate complexity during the service period
  • Face-to-face visit, within 14 calendar days of discharge
​99496 ​    Transitional care management services with the following required elements:
  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision-making of high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge
These services are for a patient whose medical and/or psychosocial problems require moderate or high complexity medical decision-making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living). TCM commences on the date of discharge and continues for the next 29 days and requires a face-to-face visit, initial patient contact, and medication reconciliation within specified timeframes. any additional E/M services provided after the initial may be reported separately.  
Refer to the CPT maual for complete details on reporting C4 and TCM services.
​Psychiatry
​+90785     ​Interactive complexity (Use in conjunction with codes for diagnostic psychiatric evaluation [90791, 90792], psychotherapy [90832, 90834, 90837], psychotherapy when performed with an evaluation and management service [90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350], and group psychotherapy [90853])
  • Refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients. Typical encounters include:
         -   Patients who have other individuals legally responsible for their care
         -   Patients who request others to be present or involved in their care such as 
             translators, interpreters or additional family members
         -   Patients who require the involvement of other third parties such as child welfare 
              agencies, schools or probation officers
Psychiatric Diagnostic or Evaluative Interview Procedures
90791 Psychiatric diagnostic interview examination ​evaluation
90792 Psychiatric diagnostic evaluation with medical services
Psychotherapy
90832 Individual psychotherapy, 20-30 min face-to-face with patient; ​
+90833      with medical evaluation and management​
90834 Individual psychotherapy, 45-50 min face-to-face with patient; ​
+90836      with medical evaluation and management services​
90837 Individual psychotherapy, 75-80 min face-to-face with patient; ​
90838      with medical evaluation and management services​
90846 Family psychotherapy (without patient present) ​
90847 Family psychotherapy (conjoint psychotherapy) (with patient present) ​
90849 Multiple-family group psychotherapy ​
90853 Group psychotherapy (other than of a multiple family group)
For interactive group psychotherapy use code 90785 in conjunction with code 90853
Other Psychiatric Services/Procedures
+90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (Use in conjunction with 90832, 90834, 90837)
  • For pharmacologic management with psychotherapy services performed by a physician or other qualified health care professional who may report E/M codes, use the appropriate E/M codes 99201-99255, 99281-99285, 99304-99337, 99341-99350 and the appropriate psychotherapy with E/M service 90833, 90836,90838).
  • Note code 90862 was deleted.
90885 Psychiatric evaluation of hospital records, other psychiatric reports, and psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes ​
90887 Interpretation or explanation of results of psychiatric, other medical exams, or other accumulated data to family or other responsible persons, or advising them how to assist patient ​
90889 Preparation of reports on patient's psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers ​
Special Otorhinolaryngologic Services
92506 Evaluation of speech, language, voice, communication, and/or auditory processing ​
92550 Tympanometry and reflex threshold measurements​
92551 Audiologic screening test, pure tone, air only ​
92552 Pure tone audiometry (threshold); air only ​
92553      air and bone​
92567 Tympanometry (impedance testing)​
92568 Acoustic reflex testing, threshold​
92570
Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing and acoustic reflex decay testing
 
(Do not report 92570 in conjunction with 92567, 92568)
​92583 ​Select picture audiometry
Central Nervous System Assessments/Tests
96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorshach,WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report ​
96102 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorshach,WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face ​
96103 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorshach,WAIS), administered by a computer, with qualified health care professional interpretation and report ​
96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, Boston Diagnostic Aphasia Examination) with interpretation and report, per hour ​
96110 Developmental testing, limited (eg, Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report ​
96111 Developmental testing, extended (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report ​
96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face with the patient and time interpreting test results and preparing the report ​
96118 Neuropsychological testing (eg, Halstead-Reitan, Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report ​
96119 Neuropsychological testing (eg, Halstead-Reitan, Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to face ​
96120 Neuropsychological testing (eg, Halstead-Reitan, Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report ​
​96127​Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.
Non-Physician Provider (NPP) Services

Prolonged Clinical Staff Services with Physician or Other Qualified Health Care

Professional Supervision

Codes 99415, 99416 are used when a prolonged E/M service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service, as stated in the code description.

+ 99415     Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour

+ 99416           each additional 30 minutes

Codes 99415-99416

  • Must always be reported in addition to an appropriate office/outpatient E/M service (ie, 99201-99215)
  • Require that the physician or qualified health care professional is present to provide direct supervision of the clinical staff.
  • Are used to report the total duration of face-to-face time spent by clinical staff on a given date providing prolonged services, even if the time spent by the clinical staff on that date is not continuous.
  • Are not reported for time spent performing separately reported services other than the E/M service is not counted toward the prolonged services time.
  • Requires a minimum of 45 minutes spent beyond the typical time of the E/M service code being reported. May require that the clinical staff spend more time if the physician does not meet the time criteria of the E/M service being reported
  • May not be reported in addition to 99354 or 99355.
99366 Medical team conference with interdisciplinary team of healthcare professionals, face-to face with patient and/or family, 30 minutes or more, participation by a nonphysician qualified healthcare professional ​
99368 Medical team conference with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more, participation by a nonphysician qualified healthcare professional ​
96150 Health and behavior assessment performed by nonphysician provider (health-focused clinical interviews, behavior observations) to identify psychological, behavioral, emotional, cognitive or social factors important to management of physical health problems, 15 min., initial assessment ​
96151      re-assessment​
96152 Health and behavior intervention performed by nonphysician provider to improve patient's health and well-being using cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems), individual, 15 min. ​
96153      group (2 or more patients)​
96154      family (with the patient present)​
96155      family (without the patient present)​
97802 Medical nutrition therapy performed by nonphysician provider; initial assessment and intervention, individual, face-to-face with patient, each 15 minutes ​
97803      re-assessment and intervention, individual, face-to-face, each 15 minutes ​
97804      group (2 or more individuals), each 30 minutes ​
Non-Face-to-Face Services: NPP
98966 Telephone assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion ​
98967      11-20 minutes of medical discussion​
98968      21-20 minutes of medical discussion​
98969 On-line assessment and management service provided by a qualified nonphysician healthcare professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous seven days nor using the internet or similar electronic communications network ​
Other Services, Procedures and Reports
99050 Service(s) provided in office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service
99051 Service(s) provided in the office during regularly scheduled evening, weekend or holiday hours, in addition to basic service
99056 Services typically provided in the office, provided out of the office at request of patient, in addition to basic service
99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service

99060


Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service
99071

Educational supplies, such as books, tapes, and pamphlets provided to patient at cost to physician 
99078

Physician educational services rendered to patients in group setting (eg, obesity or diabetic instructions) 
99080 Special reports such as insurance forms, more than conveyed in usual medical communications
99090 Analysis of clinical data stored in computers
99091

Collection and interpretation of physiologic data

​Vision-Related Services
99173 Screening test of visual acuity, quantitative, bilateral (must employ graduated visual acuity stimuli that allow a quantitative estimate of visual estimate of visual acuity — eg, Snellen chart). Note: Can only be reported when performed as a screening test and not when addressing a problem with the eye.
99174 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report
99177​Instrument-based ocular screening (eg, photoscreening, automated-refreaction), bilateral; with on-site analysis
Modifiers
22 Unusual procedural services
24 ​Unrelated E/M service performed during a post-op period
25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
32 Mandated Services
59 Distinct Procedural services (non E/M services)
76 ​Repeat procedure by the same physician on the same date or during a post-op perio

 

For more information on Coding for Bright Futures Services and Vaccine Coding, click here.

+ = Add-on Code 
*A new patient is one who has not received any professional services face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s) from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. (CPT 2014 Professional Edition, American Medical Association, page 4). Current Procedural Terminology® 2015 American Medical Association. All Rights Reserved.

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