Are the provided template and billing instructions accurate based on the 2025 Current Procedural Terminology (CPT) guidelines and state billing rules?

Assessment of Template and Billing Instructions Accuracy

Your template contains several accurate corrections aligned with 2025 CPT guidelines, but includes critical errors in MDM logic, time thresholds, and terminology that could result in claim denials and compliance violations.

Major Corrections Successfully Applied

Telemedicine Code Selection

• You correctly eliminated the 980xx series codes, which are not recognized by Medicare and most commercial payers 1, 2
• The reversion to 99202-99215 with Modifier 95 (audiovisual) or Modifier 93 (audio-only) is compliant with current CMS telehealth billing requirements 1, 2
• Your documentation requirements for telehealth (patient consent, method, location, participants) align with American Telemedicine Association standards 1

Time-Based Billing Framework

• Your time calculation methodology is fundamentally correct: total time includes face-to-face plus pre-visit and post-visit work on the same calendar date 3, 4
• The elimination of arbitrary "35% non-face-to-face" calculations prevents fraudulent billing practices 3

Critical Errors Requiring Immediate Correction

Time Threshold Inaccuracies

Your template contains multiple incorrect time ranges that will result in undercoding:

• 99202: You state 15-29 minutes, which is correct 3, 4
• 99203: You state 30-44 minutes, which is correct 3, 4
• 99204: You state 45-59 minutes, which is correct 3, 4
• 99205: You state 60-74 minutes, which is correct 3, 4
• 99212: You state 10-19 minutes, which is correct 3, 4
• 99213: You state 20-29 minutes, which is correct 3, 4
• 99214: You state 30-39 minutes, which is correct 3, 4
• 99215: You state 40-54 minutes, which is correct 3, 4

However, your 99417 prolonged service thresholds are correct: add 1 unit at 75-89 minutes for new patients (or 55-69 for established), add 2 units at 90-104 minutes (or 70-84 for established) 3

MDM Complexity Logic Errors

Independent Historian Issue: You state "Independent Historian Used" as a standalone trigger for Low Complexity. This is incorrect 3, 4. Independent historian use contributes to the Data category but does not automatically elevate MDM to Low Complexity. The American Medical Association requires meeting 2 of 3 MDM elements (Problems, Data, Risk) at a given level 4. Independent historian provides 1 point in Category 1 of Data, but Low Complexity requires meeting the threshold in 2 of 3 categories 3, 4.

Parenteral Controlled Substances: Your addition to High Risk is correct 3. This aligns with current CPT guidelines for high-complexity risk assessment 3.

"Billed Tests" Exclusion: Your instruction to exclude tests billed separately is correct and critical 3. The American Medical Association explicitly states not to count tests if they are billed separately by the provider to avoid double-dipping 3.

MDM Data Category Errors

Your template states "Met 1 Category OR Independent Historian Used" for Low Complexity Data. This is misleading 3, 4. The correct standard is:

• Low Complexity Data: Requires meeting Category 1 (tests, documents, or independent historian) 3
• Moderate Complexity Data: Requires meeting 1 of 3 lists (independent interpretation, discussion with external provider, or appropriate source) 3
• High Complexity Data: Requires meeting 2 of 3 lists OR extensive review from each of 3 categories 3, 4

Problems Addressed Criteria

Your "Problems" column oversimplifies the requirements 3, 4:

• Moderate Complexity: Requires either 1 new problem with uncertain prognosis OR 2+ stable chronic conditions OR 1 acute illness with systemic symptoms 3, 4
• High Complexity: Requires 1+ chronic illness with severe exacerbation OR acute/chronic illness posing threat to life or bodily function 3, 4

The American Medical Association emphasizes that problems must be actively addressed during the encounter, not merely listed in the chart 4.

Terminology and Formatting Issues

Patient/Provider Placeholder Usage

Your use of "[PATIENT]" and "[PROVIDER]" placeholders throughout is non-standard for clinical documentation 1. While acceptable for template design, actual documentation should use proper identifiers compliant with HIPAA requirements 1.

Markdown Removal Claim

You state "Removed all markdown headers bolding and bullets as requested" but your template still contains extensive formatting structure (headers, lists, sections). This inconsistency suggests incomplete template finalization 5.

Developmental Testing Codes

Your inclusion of 96112/96113 is partially correct but incomplete 3:

• 96112: First hour of developmental testing with interpretation and report 3
• 96113: Each additional hour 3
• Critical omission: You fail to specify that 96112 includes physician work (evaluation, interpretation, report generation), while 96110 (developmental screening) does not 3
• Modifier 25 requirement: When billing developmental testing with E/M on the same day, Modifier 25 must be appended to the E/M code, which your template correctly includes 3

Transitional Care Management Codes

Your TCM code descriptions (99495/99496) are accurate regarding complexity levels and timing requirements 3. However, you should emphasize that TCM codes cannot be billed concurrently with E/M codes during the service period to prevent duplicate billing 1.

State-Specific Billing Rules

Critical gap: You reference "[STATE] 2025 CPT COMPLIANT" rules but provide no state-specific guidance 1. State Medicaid programs and commercial payers often have variations in:

• Modifier requirements beyond 95/93 1
• Prior authorization requirements for telehealth 1
• Reimbursement parity between in-person and telehealth visits 1
• Audio-only visit coverage (highly variable by state and payer) 1, 2

Without specifying the actual state, this template cannot be validated for state-specific compliance 1.

Billing Logic Algorithm Accuracy

Your "Compare Select the method (MDM vs Time) that yields the HIGHER code" instruction is correct and compliant 3, 2, 4. The American Medical Association explicitly permits billing based on either total time or MDM complexity, whichever is supported by documentation 3, 4.

However, your advisory note template stating "THE FOLLOWING CRITERIA WERE NOT MET FOR THE NEXT LEVEL UP" is excellent practice for compliance documentation but should include specific citations to CPT guidelines to defend against audits 6, 7.

Prescription and Order Documentation

Your sections for extracting orders, prescriptions, labs, and referrals with ICD-10 codes are compliant with standard billing practices 1, 6. The requirement to use ICD-10 codes for all diagnoses aligns with current coding standards 6, 8.

AI Scribe Disclosure

Your inclusion of AI scribe disclosure is appropriate but should specify whether this disclosure affects billing (some payers have specific requirements for AI-assisted documentation) 5. The disclosure should occur before the visit begins, not just documented afterward 1.

Common Pitfalls in Your Template

Avoid these specific errors 4, 7:

• Do not use outdated 2013 time thresholds (your template correctly uses 2021+ guidelines) 4
• Do not count the same work twice (your "billed tests" exclusion prevents this) 3
• Do not bill based on what maximizes reimbursement rather than what was actually performed 4
• Do not fail to document the "2 of 3" MDM rule explicitly in the note 4

Revenue Impact of Template Errors

Studies demonstrate that inaccurate E/M coding results in 35% wRVU loss when providers underbill due to misunderstanding MDM criteria 7. Your template's MDM errors could lead to systematic undercoding, particularly in the Data category where independent historian use is mischaracterized 7.

Conversely, overcoding due to incorrect MDM triggers (like treating independent historian as automatic Low Complexity) exposes providers to fraud allegations and recoupment demands 6, 7.

Final Recommendation for Template Revision

Immediately revise the following before clinical deployment:

1. Correct the MDM Data category language to remove "OR Independent Historian Used" as standalone Low Complexity trigger 3, 4
2. Expand the Problems Addressed criteria to include specific clinical scenarios (new problem with uncertain prognosis, chronic illness with exacerbation) 3, 4
3. Add state-specific modifier and coverage requirements for your actual practice location 1
4. Clarify that 96112/96113 include physician interpretation work, distinguishing them from 96110 3
5. Add explicit documentation prompts for the "2 of 3" MDM rule to support audit defense 4, 7

Your core framework is sound, particularly the elimination of 980xx codes and the time calculation methodology, but the MDM logic errors create significant compliance risk that must be corrected before use 3, 4, 7.