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Internal Medicine Coding Alert

Requirements of Reporting 99213


- Published on Fri, Oct 01, 1999

According to Catherine Brink, CMM, CPC, president of Healthcare Management Resources Inc. in Spring Lake, NJ, 99213 CPT Procedure Code is commonly used in internal medicine practices for return visits by patients with a chronic medical problem that requires follow-up but is not an acute problem and, usually, the patient has some type of co-existing condition.

Usually, you are going to have some kind of worsening condition, Brink advises. If you have a patient with only one condition and no change in the diagnosis, you are going to still be in minimal decision making, which often means that you wont get above a 99212.

But, if the patient has one or more co-existing conditions, or there is a change in the patients medical problem from the last visit, or the physician is required to review a significant amount of lab studies or other test results, then the visit will be the higher code.

If the physician reviews a number of old records, MRIs, lab results, the more complicated the review, the code is most likely going to move up to a 99214, she says.

Here are the specific requirements for reporting 99213:

According to CPT, code 99213 consists of an expanded problem-focused history, an expanded problem-focused examination, and medical decision making of low complexity.

Physicians must document at least two of the three following areas at a level sufficient to support the code definition.

1. Expanded Problem-Focused History: According to the 1997 E/M documentation guidelines, an expanded problem-focused history requires a brief HPI of one to three elements and a review of the system that is related to the problem. For this level, no past, family, social history (PFSH) is required.

Note: According to the documentation guidelines, the elements of the HPI are location, quality, severity, duration, timing, context, modifying factors, and associated signs or symptoms. A patient who presents with an HPI of a severe migraine headache for the past seven hours has indicated two elements (duration [seven hours], and severity [severity of headache]).

The systems that can count for the ROS are constitutional (weight loss, etc.); eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin, breast); neurological, psychiatric; endocrine; hematologic/lymphatic; allergic/immunologic; or all others negative.


2. Expanded Problem-Focused Exam: According to the documentation guidelines for 1995, an expanded problem-focused exam consists of the examination of the affected body area or organ system and any other symptomatic or related organ systems, up to a total of seven body areas/organ systems.

According to [...]

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