Established Patient Office or Other Outpatient Visits

Published 02/23/2021

This electronic Comparative Billing Report (eCBR) focuses on providers who have submitted claims for Established Patient Office or other Outpatient Visit Evaluation and Management (E/M) Services (CPT codes 99211-99215). eCBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare coverage guidelines.

For your personalized eCBR results on Established Patient Visit (E/M) Services (CPT codes 99211-99215) log into our eServices portal. An eCBR will be available for providers who have at least 10 claims in history for this CPT code family during the time period selected.

Overview of CPT Codes 99211-99215
Effective January 1, 2021, the Centers for Medicare and Medicaid Services (CMS) implemented a new coding, prefatory language and interpretive guidance framework that the American Medical Association Current Procedural Terminology Editorial Panel issued for office and outpatient Evaluation and Management (E/M) visits.

  • History and exam will no longer be used to select the level of code for office/outpatient E/M visits
  • The history and exam components will be performed when they are reasonable and necessary, and clinically appropriate

For levels two (2) through five (5) office/outpatient E/M visits, selection of the code level to report will be based on the following:

  • Level of medical decision-making (as redefined in the new AMA/CPT guidance framework); or
  • The total time personally spent by the reporting practitioner on the day of the visit (including time with and without direct patient contact)
  • Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service
  • If the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use CPT code 99211

Established Patient: A patient who has received professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.

CPT CODE®
Description
99211
  • May not require the presence of a physician or other qualified health care professional
  • Usually, the presenting problem(s) are minimal
99212
  • Based on straightforward medical decision making
  • When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter
99213
  • Based on low level of medical decision making
  • When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter
99214
  • Based on moderate level of medical decision making
  • When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter
99215
  • Based on high level of medical decision making
  • When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter

You can find more information on the outpatient and office visit changes in the RRM SMAC article, 2021 Medicare Final Rule: Evaluation and Management Changes.

Methods:
The metrics reviewed in this eCBR are the proportion of billing for each CPT code in the E/M grouping with comparisons to peers within the nationwide Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) Jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your claims for CPT codes 99211-99215 at levels compared to your peers in the RRB SMAC.

Example of eCBR Results from eServices:

eCBR Lookup 

Please be aware that the information contained within this eCBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

For more information about this or other eCBRs, please call our Provider Contact Center at 888-355-9165, and select Option 5. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. - 4:30 p.m. in all time zones with the exception of Pacific Time. This service is available from 8:30 a.m. - 4 p.m. PT.

Educational Resources:
CMS Resources

Palmetto GBA Railroad Medicare Resource