When to Use 99205 CPT Code in Outpatient Visits

The 99205 cpt code is the most advanced indication of new office visit services to a patient. It is when you have a case that needs your full attention and experience.

This code is specifically applicable in the behavioral health field especially when complex psychiatric diagnostic assessment is involved. Consider the first patient meetings when a patient is severely mentally ill or extensive suicide risk assessment or co occurring disorders. Such cases are more time consuming and require a greater degree of clinical judgment.

This guide will assist you in making appropriate documentation whether you qualify on time basis or medical decision making basis. We are determined to assist  medical and behavioral health providers to maximize compliant revenue and remain immune to audit risks.

Understanding the 99205 Code for New Patients

99205 cpt code is applied to office/other outpatient visits with a new patient. It represents a visit, which entails an extensive history, a thorough examination, and the highest complexity medical decision making.

Knowledge about the new patient rule is very important. A patient will be considered new when he has not been subjected to any professional service in your group practice or any other physician within the same specialty within 3 years. This should be checked prior to the visit to avoid billing mistakes.

Two different systems are used to qualify the 99205 cpt code.

• Time Based: This route needs a minimum amount of 60 minutes of total provider time during the date of encounter. This involves face to face and non face to face time.
• Based on Medical Decision Making: This route is very complex in the diagnosis and treatment of the patient. You concentrate on the acuity of the issues, the information that you are reading, and the risk.

Qualifying Through the 60 Minute Time Rule

Total time is not the same as face to face time was. In the case of the 99205 cpt code, time is considered to entail everything you do on the day you visit the patient, regardless of whether you are with the patient in the room or not.

Numerous activities would be included in the 60 minutes requirement of the 99205 cpt setting.

• Psychiatric history and review of external records prior to the arrival of a patient.
• Conducting an extensive mental status examination on the visit.
• Follow-ups with family members, schools, or other providers once the patient is discharged.
• Writing up the encounter and compiling the clinical note.

The 60 minute time is not lenient. In order to charge the 99205 cpt code based on time, you have to reach the time of at least 60 minutes. In case you spend 59 minutes, you can not employ this code using time alone. You would then have to determine whether your medical decision making upholds it.

Meeting the High Complexity MDM Standard

In case your visit date is below 60 minutes, you are also allowed to charge the 99205 cpt code. The key is to prove that your medical decision making was at an advanced stage.

The high complexity medical decision making involves certain elements that should be included in your documentation.

• Issues: You are dealing with several serious problems or one problem which is threatening the life or functioning of the patient. This may be acute psychosis and homicidal ideation in behavioral health.
• Information: You conducted a comprehensive examination of documentation, obtained collateral history, or examined complicated tests.
• Risk: There is a high chance of morbidity or mortality of the patient due to his or her condition or your choice of a treatment.

Adding Prolonged Services Code 99417

There are also visits that are longer than the normal range of the 99205 cpt code. When the cumulative time is greater than the base service, a prolonged service code can be added.

In case the encounter takes 75 minutes or more, then you need to add the extended services code +99417 to the basic 99205 cpt code. This code captivates every extra 15 minutes over the first 60-74 minutes interval.

Payers discrepancies over extended services should also be noticed. Although the guidelines of the Current Procedural Terminology establish prolonged services as beginning at 75 minutes, other payers such as Medicare establish varying thresholds. It might take Medicare 89 minutes to make use of their particular code G2212. There are certain policies of payer which should be checked to be properly billed.

Behavioral Health Use Cases for 99205

The cpt code 99205 can be useful in a number of ways in the behavioral health setting. These concepts of use cases make you realize when the code can be used.

Initial Psychiatric Assessment: In the case of a thorough 60 minute or more diagnostic interview, the 99205 cpt code would be suitable. This is applicable in the situations where Evaluation and Management element is dominant, particularly when it is combined with medical management.

It is inherently complicated when assessing a new patient in the office after the emergency department discharge of acute mental health problems. The 99205 cpt code is justified by this situation.

Complex Co Occurring Disorders: A patient with a severe mental illness with substance use disorder and unstable comorbidity of the medical history should be assessed at the best level. This intensity of the work is captured in the 99205 cpt code.

Documentation Requirements for the 99205

• When you are time coded, then your documentation should be particular. It is not just sufficient to mention the overall time.

Record the amount of time spent during the encounter date.

Note down the exact activities done at the same time. As an example, 45 minutes on history and exam, 20 minutes on coordination with the family and review of past records.

• In case medical decision making is the method of codes, your documentation should be able to support the complexity.

Write down clearly the severity of the condition, and the risk to the patient and the information that you read.

Provide an appropriate history and exam that upholds the level of service.

• Apply checklist thinking to each 99205 cpt code note. Make sure that the chief complaint, a definite time log, when there is time to use, and the signature of the provider, as well as an explicit explanation of the degree of complexity, are included in the note.

Avoiding Frequent 99205 Billing Errors

A cpt code of the 99205 is one of the most common mistakes that is billed on the established patients. The codes 99202 to 99205 are only applicable to a new patient. In the case of existing patients, the range to be used is 99211-99215.

This code has a major risk of downcoding. In situations where documentation is not adequate to substantiate 60 minutes or high complexity 99205 cpt code will automatically be downcoded to a lower level such as 99204 which is moderate complexity.

The other most frequent error is to count an incorrect kind of time. The providers occasionally involve personnel time or pre services and post services which take place on alternate days. The time of the encounter on the date of the encounter is only counted towards the total of the 99205 cpt code by the provider.

How 99205 Differs From Other New Patient Codes

The knowledge of the code placement of 99205 cpt is useful in choosing the appropriate level on any occasion.

• 99202: This code applies to simple issues. Its total time takes between 15 and 29 minutes.
• 99203: This is a low-complexity code. It takes a total time of between 30 and 44 minutes.
• 99204: This code is moderate in complexity. It has a total time ranging between 45 and 59 minutes.
• 99205: This code is of high complexity. It takes between 60 and 74 minutes in total. It is positioned on the top of the new patient code range.

Final Thoughts

The 99205 cpt code is an efficient and much-needed code to capture the intensity work done in complicated behavioral health intake assessments. It will make sure that your time and experience is not wasted.

The providers should take the best practice to use the time based rule whenever feasible. This gives you the ability to showcase all the amount of work you have done without having to be confined by the physical exam of the old school, and the bullet points. Pay attention to tracking your total time and activities you do.

You do not need to go it alone unless your practice has the problem of unsuccessful claims or complicated code sets. 

Contact Billing Care Solutions today . We are the company that focuses on assisting the providers to optimize their revenue cycle, as well as enhance their coding accuracy.

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