What are the current billing guidelines for codes 99202, 99204, 99205, 99212, 99213, 99214, 99215, 99293, and 99417, as well as procedure codes for Autism Diagnostic Interview-Revised (ADI-R), Montreal Cognitive Assessment (MIGDAS-2), Developmental Profile 4 (DP-4), Diagnostic Assessment of Adaptive Skills (DABS), and Test of Dyslexia (TOD) based on time and Medical Decision Making (MDM)?

Current Billing Guidelines for E/M and Diagnostic Testing Codes

Office/Outpatient E/M Codes: Time and MDM Requirements

For all office visit codes (99202-99205,99212-99215), you can bill based on either total time spent on the date of encounter OR medical decision-making complexity—choose whichever yields the appropriate level of service. 1

New Patient Visits (99202-99205)

• 99202: 15-29 minutes total time OR straightforward MDM 1
• 99203: 30-44 minutes total time OR low complexity MDM 1
• 99204: 45-59 minutes total time OR moderate complexity MDM 1
• 99205: 60-74 minutes total time OR high complexity MDM 1

Established Patient Visits (99212-99215)

• 99212: 10-19 minutes total time OR straightforward MDM 1
• 99213: 20-29 minutes total time OR low complexity MDM 1
• 99214: 30-39 minutes total time OR moderate complexity MDM 1
• 99215: 40-54 minutes total time OR high complexity MDM 1

Critical Care Code (99293)

CPT 99293 is not a standard outpatient code—this represents critical care services for each additional 30 minutes beyond the first 74 minutes (reported with 99291). 2 This code requires constant physician attention to a critically ill or injured patient and is time-based, requiring documentation of total time spent providing critical care services. 3

Prolonged Services Add-On (99417)

99417 is used for prolonged office/outpatient E/M services beyond the maximum time for 99205 or 99215. 4 Report this code for each additional 15 minutes of total time beyond 75 minutes for new patients (with 99205) or 55 minutes for established patients (with 99215). 4

MDM Complexity Determination

To qualify for a specific MDM level, you must meet 2 out of 3 elements: number/complexity of problems addressed, amount/complexity of data reviewed, and risk of complications. 1

Key MDM Rules:

• Problems must be actively "addressed" during the encounter, not merely listed in the chart 1
• "Undiagnosed new problem with uncertain prognosis" qualifies as moderate complexity 1
• High complexity MDM requires "extensive" data review: 3 points from Category 1 OR 2 points from Category 2 1
• If 2 of 3 MDM elements meet moderate complexity, the overall MDM is moderate 1

Billing Strategy

Calculate both time-based and MDM-based code levels for each encounter, then bill whichever is supported by your documentation and yields the appropriate level. 1 Time-based billing requires documenting total face-to-face time with the patient. 2 The 2021 coding changes eliminated physical examination documentation requirements for supporting code levels, facilitating billing for both in-person and telemedicine visits. 2

Diagnostic Testing Procedure Codes

Autism and Developmental Testing:

• ADI-R (Autism Diagnostic Interview-Revised): Use CPT 96110 for developmental screening (non-physician staff administration) or 96111 for extended developmental testing by the physician (up to 1 hour including interpretation and report) 4
• MIGDAS-2: No specific CPT code exists; bill using 96110 for screening or 96111 for extended evaluation 4
• DP-4 (Developmental Profile 4): Use 96110 for screening administration or 96111 for comprehensive developmental testing 4

Adaptive and Learning Assessment:

• DABS (Diagnostic Adaptive Behavior Scale): Use 96110 for screening or 96111 for extended testing with interpretation 4
• TOD (Test of Dyslexia): Use 96111 for extended developmental/behavioral testing including interpretation 4

Important Testing Billing Rules:

• 96110 does not include physician work—it covers non-physician staff administering and scoring the tool, while physician interpretation is bundled into the E/M code. 4
• 96111 includes physician evaluation, interpretation, and report generation. 4
• When billing 96110 or 96111 with an E/M service on the same day, append modifier 25 to the E/M code to indicate a separately identifiable service 4

Common Pitfalls to Avoid

• Do not use outdated 2013 time thresholds—the 2021 guidelines significantly changed time requirements. 1 For example, 99214 now requires 30-39 minutes, not 25 minutes. 1
• Do not bill standard office visit codes (99211-99215) for routine wellness care when dedicated preventive care codes (99381-99394) exist. 4
• Do not fail to document which 2 of 3 MDM elements meet the complexity level you're billing. 1
• Do not use telemedicine codes without appropriate Place of Service codes and telehealth modifiers (e.g., modifier 95, GQ, or GT). 2
• Undercoding is extremely common in primary care settings, with studies showing 72% of visits coded as 99213 or lower could have been billed at higher levels 5