99213 RequirementsHCPCS code G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact …. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. CPT 99211, 99212, 99213, 99214, 99215. ) 99203/99213 19 19 Example - 12yo is seen in the office for ADHD and anxiety follow up. The new prolonged service CPT code 99417 will be in increments of 15 minutes. Modifier 25 is appended to code 99213 to identify a significant and separately E/M service was performed by the same physician on the same date of service as preventive screening services. These guidelines apply to common visit billing codes, such as 99212, 99213, 99214, or 99215, as well as to the selection of codes 99202 through 99205. Billing and Coding: Routine Foot Care and Debridement of Nails">Billing and Coding: Routine Foot Care and Debridement of Nails. HCPCS code G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact …. The 99213 is the second most popular choice for internists who selected this level of care for 29. However, if the 99442 resulted in the 99213 within 24 hours, or if the 99442 was a follow-up to the 99213 within the previous seven days, you can only bill for the 99213 with modifier. This is representative of what I see in our office. If using MDM for the level of service, there is no requirement to spend the correlating amount of time on the encounter. Be prepared for 2021… Office E/M Coding Changes. A: To bill 99441-99443 and an evaluation and management (E/M) service such as 99213, you must follow CPT® guidelines, which state, “If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of …. These codes require two or more encounters on the same date, one being an initial admission encounter and another being a discharge encounter. 1) Based on MDM: In the below table it has to meet atleast one criteria from any 2 sections for CPT 99213. Each visit will have range of time; for example, CPT 99213 will be 20-29 minutes and 99214 will be 30-39 minutes. The following tips can help you recognize when a visit meets the requirements of a 99214, as opposed to a 99213. Answer: 99213. For code 99213, the expanded assessment for office or other outpatient visit requires at least two out of these three key components to be present in the medical record: An expanded problem focused history An expanded problem focused examination Medical decision making of low complexity. Four elements of the history of. Append modifier -95 to the appropriate level of exam. Subscribe to Codify by AAPC and get the code details in a flash. Code 99213 requires a problem-pertinent ROS, meaning that only a review of the system directly related to the problem (s) found in the HPI must be documented. A: To bill 99441-99443 and an evaluation and management (E/M) service such as 99213, you must follow CPT® guidelines, which state, “If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of …. Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service. CPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. For adult members who do not achieve a weight loss of at least 3 kg (6. Caregiver emotions/behavior that interfere with implementation of the treatment plan. Breaking the Code">Optometric Management. • E/M Introductory Guidelines related toHospital Inpatient and Observation Care Services codes 99221-99223, 99231-99239, Consultations codes 99242- 99245, 99252-99255, Emergency Department Services codes 99281-99285, Nursing Facility Services codes 99304-99310, 99315, 99316, Home or Residence Services codes 99341, 99342, 99344, 99345, 99347-99350. Moderate 99204/ 99214 High 99205/ 99215 1 or more chronic illness with • 1 or more chronic illness with minor problem problems, OR 1 stable chronic illness, OR 1 acute, uncomplicated illness exacerbation, progression, or side effects for treatment, OR severe exacerbation, progression, or side effects of. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Example: Uncomplicated appendicitis. Procedure Code 99213 Time Length: 15 minutes in length, as determined by their level of risk and complexity of treatment. Modifier 25 is appended to code 99213 to identify a significant and separately E/M service was performed by the same physician on the same date of service as preventive screening services. Centers for Medicare & Medicaid Services">CMS Manual System. 31% of these encounters in 2020. A: The familiar Eye exam codes we commonly use: 92002; 92004; 92012; and 92014, don’t change in documentation or coding requirements and there’s no move to change them. The Key Components – History, Examination, and Medical Decision Making – must be considered in determining the appropriate code History: Type of History : Problem focused HPI : Brief (1-3 element) Examinaation : Type of Exam : Problem focused Details of Examination : Limited-affected area or organ system Medical Decision Making. , barium enema); Superficial needle biopsy; ABG; Skin biopsies. Smith would report CPT code 99213 (i. 99213Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components. Were the physician's or other qualified health care professional's evaluation and management of the problem significant and beyond the normal preoperative and postoperative work? If Yes, an E/M may be billed with modifier 25 If No, it is not appropriate to bill with modifier 25 Example:. 15 minutes ago · スケートボード男子ストリートで優勝した小野寺吟雲. These visits must be provided by a qualified health care provider. Expanded problem focus history; 2. CPT® code 99213: Established patient office or other outpatient visit, 20-29 minutes. After a decision to perform the surgery is made, any preoperative or postoperative visits will be considered to be part of the bundled payment for the surgery. 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key. • E/M Introductory Guidelines related toHospital Inpatient and Observation Care Services codes 99221-99223, 99231-99239, Consultations codes 99242- 99245, 99252-99255, Emergency Department Services codes 99281-99285, Nursing Facility Services codes 99304-99310, 99315, 99316, Home or Residence Services codes 99341, 99342, 99344, 99345, 99347-99350. 99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires two of three of these components. Medical decision making of low complexity. CPT 99211, 99212, 99213, 99214, 99215 – Established patient. • 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components. Usually the presenting problem(s) are of low to moderate severity. The Key Components – History, Examination, and Medical Decision Making – must be considered in determining the appropriate code History: Type of History : Problem focused HPI : Brief (1-3 element) Examinaation : Type of Exam : Problem focused Details of Examination : Limited-affected area or organ system Medical Decision Making. For a level-II visit, you need one point to meet the data requirement, which is considered minimal. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. Which code would you choose? Answer: 99213. The patient must have a medical history. According to Current Procedural Terminology (CPT) guidance, superficial radiation (up to 200 kV) should not be reported with CPT codes for planning and management, and the professional component associated with this service should be reported with the appropriate E/M codes. Treatment requires hospital inpatient or observation setting. To be eligible for using CPT Code 99213, patients must: Be established patients with an ongoing relationship with the provider. The physician conducted a review of tumor marker, CBC, CMP (moderate level of data reviewed). There is no requirement to document the total time spent if the physician is not using time to calculate the level of service. The following tips can help you recognize when a visit meets the requirements of a 99214, as opposed to a 99213. 99211-99215: Established Patient Office Visits Code selection – Medical Decision Making (MDM) or Time Medical decision making (MDM) Time Although you should still perform a medically appropriate history and/or physical exam, it/they do not determine the level of service. Provided the documentation shows there is no relationship between the 99213 and 99442, you can then bill for both services using modifiers 25 and 95 on the 99213. 99213 with an allowable of $142. Often questions are posed regarding whether to bill an E/M visit on the same day as a procedure and/or. Documentation Guidelines for 2021">New E&M Coding and Documentation Guidelines for 2021. Combining a Wellness Visit With a Problem. Moderate 99204/ 99214 High 99205/ 99215 1 or more chronic illness with • 1 or more chronic illness with minor problem problems, OR 1 stable chronic illness, OR 1 acute, uncomplicated illness exacerbation, progression, or side effects for treatment, OR severe exacerbation, progression, or side effects of. CPT® code 99213: Established patient office or other outpatient visit, 20-29 minutes. Coding Information CPT/HCPCS Codes Expand All | Collapse All Group 1 (9 Codes) Group 1 Paragraph. If the eye code pays better than the E/M code that you can also code for, then stay with it. The need to manage maladaptive communication (related to, e. A clear statement of the low level of medical decision making involved in the encounter. The presenting problem characteristic of a 99213visit consists of: one stable chronic illness, two or more self-limited illnesses or an acute uncomplicated illness. An example is 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. Low complexity medical decision making. PDF 2023 Evaluation and Management Changes: Medical Decision Making Simplified. Established Patient 99213 Documentation Requirements When reporting for telemedicine • Modifier -95 may be required depending on the payer • Place of service is. Note: Medical decision making. CPT Code 99213 Definition: Evaluation and management of an established patient in an office or outpatient location for 15 minutes. New E&M Coding and Documentation Guidelines for 2021. CPT® code 99213: Established patient office or other outpatient visit, 20-29 minutes. As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care. 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. When using time for code selection, it requires total of 20-29 minutes on the same date of service. 14日 「Xゲームズ千葉」最終日（ZOZOマリンスタジアム） スケートボードの男子ストリートは、2月の世界選手権で史上最年少メダルに輝いた13歳の. CPT® code 99213: Established patient office or other outpatient visit, 20-29 minutes As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care. Medical decision making must be 1 of the 2 components 1. CPT codes 99234-99236 are used to report hospital inpatient or observation care services provided to patients admitted and discharged on the same date of service. 2) Based on Time: A total of 20-29 minutes (apart from. For CPT Code 992213, an outpatient or inpatient office visit that is considered to be a mid-level visit can be billed with this code. Were the physician's or other qualified health care professional's evaluation and management of the problem significant and beyond the normal preoperative and postoperative work? If Yes, an E/M may be billed with modifier 25 If No, it is not appropriate to bill with modifier 25 Example:. Effective January 1, 2021, this level of care requires low complexity MDM or 20 - 29 minutes before, during and after the visit on the date. To be eligible for using CPT Code 99213, patients must: Be established patients with an ongoing relationship with the provider. CPT codes 99234-99236 are used to report hospital inpatient or observation care services provided to patients admitted and discharged on the same date of service. Evaluation and Management Changes for 2021. CPT 99213 Code Description: Office or other outpatient visit E&M code of established patient requires medically appropriate history and/or exam with MDM of low level. E/M coding and documentation rules. The documentation also supports an established intermediate Eye visit code, 92012 with an allowable of $170. For a 99213 office visit, six to eight elements are required for the exam component; for a 99214 visit, nine elements are required. Substantiation of this level of coding requires eitherof the following: At least one HPI element A Review of Systems pertinent to the problem. The only difference between the history requirements for a 99212 and a 99213 is the review of systems. The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30–39 minutes. 99213: 20-29 mins 99214: 30-39 mins 99215: 40-54 mins Important notes There is no requirement to document the total time spent if the physician is not using time to calculate the level of service. When to Use CPT Code 99213. The CPT requirements for these two codes are shown side by side. JUST HOW MUCH DOCUMENTATION IS REQUIRED. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45–59 minutes. 99213 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An. If time were used for code selection, Dr. CPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an. In this case, the note addresses. All covered service fees (G0101, Q0091, and 99213) are deducted from the preventive medicine service. Chronic illness with exacerbation, progression, or side effects of treatment:. Moderate 99204/ 99214 High 99205/ 99215 1 or more chronic illness with • 1 or more chronic illness with minor problem problems, OR 1 stable chronic illness, OR 1 acute, uncomplicated illness exacerbation, progression, or side effects for treatment, OR severe exacerbation, progression, or side effects of. CPT 99211, 99212, 99213, 99214, 99215 – Established patient …. Documentation requirements To support a claim for CPT 99213, providers must document the following information: A description of the medically appropriate history and/or examination performed by the provider. CPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Time with staff should not be included. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or. Counseling and coordination of care with other physicians, other. Code 99213 requires a problem-pertinent ROS, meaning that only a review of the system directly related to the problem (s) found in the HPI must be documented. An expanded problem-focused physical exam. • 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components. 99213 Performed Via Telehealth?">What Constitutes E/M 99213 Performed Via Telehealth?. Note: Medical decision making must be one of the two components. Modifier 25 is appended to code 99213 to identify a significant and separately E/M service was performed by the same physician on the same date of service as preventive screening services. Physician Fee Schedule (PFS) Payment for Office/Outpatient. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30-39 minutes. Procedure Code 99213 Time Length: 15 minutes in length, as determined by their level of risk and complexity of treatment. The proper billing would be 99213 25 and 20520. 2022 Changes to outpatient evaluation and management codes. 6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period. 2021 Guidelines – 99203/99213MedicalLow: Acute Decision-Making uncomplicated illness or injury – 99203/99213 Straightforward: 1 test ordered, reviewed – 99202/99212 Low: (No examples given. For code 99213, the expanded assessment for office or other outpatient visit requires at least two out of these three key components to be present in the medical. If time were used for code selection, Dr. 99213: 20-29 mins 99214: 30-39 mins 99215: 40-54 mins Important notes There is no requirement to document the total time spent if the physician is not using time to calculate the level of service. Child is on Adderall and sertraline. The proper billing would be 99213 25 and 20520. 99212, 99213 visit history. , PFTs); Non-cardiovascular imaging studies with contrast (e. CPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30–39 minutes. CPT Code 99213 Definition: Evaluation and management of an established patient in an office or outpatient location for 15. New Prolonged Service Code Beginning in 2021, there will be a new code for reporting prolonged service with an office visit. 14日 「Xゲームズ千葉」 最終日 （ ZOZOマリンスタジアム ） スケートボードの男子. OHSU">Getting Ready for 2021. Request a Demo 14 Day Free Trial Buy Now Additional/Related Information Lay Term CPT ® Code Guidelines. 2021 E/M coding and documentation rules. 99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Coding Level 4 Office Visits Using the New E/M Guidelines. Documentation requirements for a preventive visit such as an "annual physical" include an age- and gender-appropriate history and physical examination, counseling or anticipatory guidance, and risk factor reduction interventions. The 2021 Office Visit Coding Changes: Putting the Pieces Together. CPT 99213 Code Description: Office or other outpatient visit E&M code of established patient requires medically appropriate history and/or exam with MDM of low level. Smith spends 5 minutes reviewing a patient’s chart while clinical staff gowns the patient and takes vitals. (See "Indications and Limitations of Coverage. When using time for code selection, 20–29 minutes of total time is spent on the date of the encounter. Documentation Requirements: The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. , high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care. A: The familiar Eye exam codes we commonly use: 92002; 92004; 92012; and 92014, don’t change in documentation or coding requirements and there’s no move to change them. 99212 and 99213. 99213: 15 minutes 99214: 25 minutes 99215: 40 minutes The times above are published in CPT 2020. Use time for coding whether or not 10-19 minutes counseling and/or coordination of care 99213 99214. As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care. 99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires two of three of these components. 99213: 20-29 mins 99214: 30-39 mins 99215: 40-54 mins Important notes There is no requirement to document the total time spent if the physician is not using time to calculate the level of service. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45-59 minutes. Evaluation and Management (E/M) Code Changes 2021. If you don’t fully document the work you do in a. 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2. Time is all of the physician time associated with the E/M service on the day of the encounter. Coding Preventive Care Services. Code 99213 requires a problem-pertinent ROS, meaning that only a review of the system directly related to the problem (s) found in the HPI must be documented. Using time for E/M Codes Preparing to see the patient (e. The visit involves a low level of medical decision making and/or the provider spends 20–29 minutes of total time on the encounter on a single date. ) Obtaining and/or reviewing separately obtained history Performing a medically appropriate examination and/or evaluation Counseling and educating the patient/family /caregiver Ordering medications, tests, or procedures. Ensuring Coding and Claims Accuracy. As you can see, the difference between the two can be slight. Scenario B: On the day of the visit, Dr. Physiologic tests not under stress (e. Established Patient 99213 Documentation …. These guidelines apply to common visit billing codes, such as 99212, 99213, 99214, or 99215, as well as to the selection of codes 99202 through 99205. A legible countersignature or identity alone. This commercial insurance requires E/M codes when a medical diagnosis is the primary diagnosis and only accepts eye visit codes for routine or annual exams. Require low-level medical decision-making. Have a total encounter time of 20-29 minutes, including face-to-face and non-face-to-face activities. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. 99213: 20-29 mins 99214: 30-39 mins 99215: 40-54 mins Important notes There is no requirement to document the total time spent if the physician is not using. 99211-99215: Established Patient Office Visits Code selection – Medical Decision Making (MDM) or Time Medical decision making (MDM) Time Although you should still perform a medically appropriate history and/or physical exam, it/they do not determine the level of service. Have a total encounter time of 20-29 minutes,. Expanded problem focused examination; 3. The only difference between the history requirements for a 99212 and a 99213 is the review of systems. Each visit will have range of time; for example, CPT 99213 will be 20-29 minutes and 99214 will be 30-39 minutes. 2021 Guidelines – 99203/99213MedicalLow: Acute Decision-Making uncomplicated illness or injury – 99203/99213 Straightforward: 1 test ordered, reviewed – 99202/99212 Low: (No examples given. CPT Code 99213 Definition: Evaluation and management of an established patient in an office or outpatient location for 15 minutes. All covered service fees (G0101, Q0091, and 99213) are deducted from the preventive medicine service. All requirements for the E&M code selected must be met to bill the appropriate level of care. Data show that family physicians choose 99213 for about 61 percent of visits with established Medicare patients and choose 99214 only about 23 percent of the time for. CPT Code 99213 Definition: Evaluation and management of an established patient in an office or outpatient location for 15 minutes. 99212 and 99213: Decide Which Code to Use for ">CPT Codes 99212 and 99213: Decide Which Code to Use for. An expanded problem focused history An expanded problem focused examination Low complexity medical decision making. CPTCode 99213 can only be used for an already established patient. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. In a typical 99213 visit, you may not need to review or update the patient’s PFSH at all, but a 99214 requires at least one of those areas be reviewed and documented. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Yet, it should be no surprise to see that this code is very popular. Billing and Coding: Routine Foot Care and Debridement of Nails. If using MDM for the level of service, there is no requirement to spend the correlating amount of time on the encounter. The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30–39 minutes. The Current Procedural Terminology (CPT ®) code 99213 as maintained by American Medical Association, is a medical procedural code under the range - Established Patient. All requirements for the E&M code selected must be met to bill the appropriate level of care. CPT code: 99213 Explanation: Under the 2021 guidelines, low-level MDM involves at least two of the following: Low number and complexity of problems addressed at the encounter, Limited amount. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. 99213Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components. The 2022 Medicare allowable reimbursement for this level of care is $92. • 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components. These guidelines apply to common visit billing codes, such as 99212, 99213, 99214, or 99215, as well as to the selection of codes 99202 through 99205. 99213. CPT code: 99213 Explanation: Under the 2021 guidelines, low-level MDM involves at least two of the following: Low number and complexity of problems addressed at the encounter, Limited amount. Select a Code Based on Medical Decision Making You can base your visit level code on medical decision making, which is comprised of three elements:. Medical decision making must be 1 of the 2 components Expanded problem focus history; Expanded problem focused examination; Medical decision making of low complexity. Example: A low-level E/M code (99203, 99213) would be reported if: A patient presented with a stable history of breast cancer no longer on treatment (low level or problems addressed). , 20-29 minutes total time), even though the presenting problem was minor and required no treatment. 99213 or 99214? Three Tips for Navigating the Coding …. Remember 4, 2, 1 for a detailed history. For a 99213 office visit, six to eight elements are required for the exam component; for a 99214 visit, nine elements are required. Both 99211 and 99215 account for less then 2% of total office visits in eye care for established patients. CPT® code 99213: Established patient office visit, 20. Document time in the medical record when used for the basis for the code. First and foremost, you need to understand the unique documentation requirements for the two options. Documenting time for each task during outpatient visits. Coding Information CPT/HCPCS Codes Expand All | Collapse All Group 1 (9 Codes). Modifier 25 is appended to code 99213 to identify a significant and separately E/M service was performed by the same physician on the same date of service as preventive. For adult members who do not achieve a weight loss of at least 3 kg (6. The Current Procedural Terminology (CPT ®) code 99213 as maintained by American Medical Association, is a medical procedural code under the range - Established Patient. E/M coding for outpatient services. The proper billing would be 99213 25 and 20520. Each visit will have range of time; for example, CPT 99213 will be 20-29 minutes and 99214 will be 30-39 minutes. The physician documents the extra work, then bills code 99396 for a periodic preventive medicine visit for a patient age 40–64 and E/M code 99213 for addressing two acute illnesses (fatigue and. The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. A legible countersignature or identity alone. The patient is considered an established patient. 2021 Revised E/M Coding Guidelines: 99202. Documentation Requirements: The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. Q: I heard the level 1 exam codes are being deleted.