CPT 99201, 99202, 99203, 99204, 99205 - Which code to USE

CPT - 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problems are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

CPT - 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.


CPT 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

Physicians typically spend 30 minutes face-to-face with the patient and/or family.


CPT 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.

CPT 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and
medical decision making of high complexity. Counseling and/or coordination of care with other
providers or agencies are provided consistent with the nature of the problem(s) and the patient's
and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians
typically spend 60 minutes face-to-face with the patient and/or family

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Insurance denial - CO 146 - Payment denied because the diagnosis was invalid

CO 146 - Payment denied because the diagnosis was invalid for the date(s) of service reported.


Description:
The following types of rejections are possible; Diagnose code does not match with the procedure code (check in LMRP). The Diagnose code reported on the claim is not to the highest level of specificity. Diagnose code is no longer valid.  


    Action: Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry, if yes, then correct it and resubmit the claim.  If no, it may be because of incorrect Diagnose code. It is possible that the 4 digit Diagnose code used is not the highest level of specificity and the carrier wants a five digit Diagnose code. Coders will also have to recheck to see if the diagnosis code used has been deleted, if it matches with the procedure code and if it is of the highest level of specificity and if not find the right diagnosis code, and submit the claim with the correct diagnosis code.

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Insurance denial - IMPROPER DIAGNOSIS or INCORRECT DIAGNOSIS

IMPROPER DIAGNOSIS or INCORRECT DIAGNOSIS

Description:
Services were denied because the diagnosis listed as primary was not a covered diagnosis for the procedures performed.

ACTION:

Check your specific carrier's local coverage determination (LCD) policy for the specified procedure to obtain a list of covered diagnoses, generally found on their Web site, or accessible on Medicare's Web site. Also familiarize yourself with the appropriate policies for medical necessity and documentation requirements. Be cautious of automated programs/software that provide a covered diagnosis for any given procedure. Keep in mind that having a covered diagnosis does not mean you can automatically perform any procedure for which the covered diagnosis exists. You must prove and document the reason in the medical record to justify doing the procedure. For example, let's look at doing routine anterior segment photography because your patient presents with allergic conjunctivitis. Despite having a "covered diagnosis" for taking the photo, there most likely is insufficient medical necessity to take an annual photo of the allergic eye.

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