What are the Current Procedural Terminology (CPT) codes, modifiers, and their appropriate usage in an outpatient family medicine clinic setting by a primary care provider or staff?

From the Guidelines

CPT codes for outpatient family medicine include evaluation and management codes 99202-99205 for new patients and 99212-99215 for established patients, with selection based on complexity and time spent, as outlined in the 2013 study 1. When selecting CPT codes, it is essential to consider the level of complexity and time spent on each patient visit.

• Evaluation and management codes 99202-99205 are used for new patients, while codes 99212-99215 are used for established patients.
• Preventive visit codes, such as 99381-99387 for new patients and 99391-99397 for established patients, are also crucial in outpatient family medicine.
• Procedure codes, including 36415 for venipuncture, 93000 for ECG, 94010 for spirometry, 20610 for major joint injection, 11730 for nail removal, and 17110 for wart destruction, are frequently used in outpatient family medicine. Important modifiers, such as 25 (separate E/M service), 59 (distinct procedural service), 24 (unrelated E/M during postoperative period), and 95 (synchronous telemedicine), must be used appropriately to ensure accurate billing and reimbursement.
• The -25 modifier is used to indicate a separate E/M service, as recommended in the 2009 study 1.
• The -59 modifier is used to indicate a distinct procedural service.
• The -24 modifier is used to indicate an unrelated E/M service during the postoperative period.
• The -95 modifier is used to indicate synchronous telemedicine services. Proper documentation is critical to support the level of service billed, including history, examination, medical decision-making complexity, and time spent.
• For time-based billing, it is essential to document total face-to-face time and specific activities performed.
• When billing for procedures, it is necessary to document medical necessity, specific technique, anatomical location, and any complications. Regular updates to coding knowledge are essential as guidelines change annually, and staff should verify insurance coverage before services and understand which services require prior authorization to prevent claim denials.

From the Research

Current Procedural Terminology (CPT) Codes and Modifiers

• CPT codes are used to describe medical, surgical, and diagnostic services 2, 3
• Modifiers are used to provide additional information about the service performed, such as the level of complexity or the location of the service 2

Appropriate Usage in an Outpatient Family Medicine Clinic Setting

• Primary care providers and staff should use CPT codes and modifiers accurately and consistently to ensure proper billing and reimbursement 2, 3
• The Medicare Primary Care Exception (PCE) allows residents to see and bill for less-complex patients independently in the primary care setting, requiring attending physicians only to see patients for higher-level visits and complete physical exams in order to bill for them as such 2
• Family medicine residency programs may need to adapt to meet the current and future practice needs of an increasing older adult population, including performing clinic procedures essential to older adults 3

Coding Practices and Revenue Loss

• Residents at family medicine programs that apply the PCE to all patients bill significantly fewer high-complexity visits, leading to compliance and regulatory concerns and significant revenue loss 2
• The estimated revenue loss over the 1,650 RRC-required outpatient visits was $2,558.66 per resident and $57,569.85 per year for the average residency in the sample 2

Quality and Experience of Outpatient Care

• Receipt of primary care is associated with significantly more high-value care, slightly more low-value care, and better health care experience 4
• Americans with primary care received more high-value care in 4 of 5 composites, including cancer screening, and reported significantly better health care access and experience 4