Hi Hughtellerdds!

Great question. The office visit code you select will depend on a few things:

1) What level of documentation was collected
2) What level of exam was performed
3) What level of medical decision was performed

or

1) How long did the doctor spend face to face with the patient (this can only be used as the key factoring for selecting the code is 50% of the doctor's face to face time was spent counseling the patient.....if this is the case, make sure you document how long the doctor spent face to face with the patient and that at least 50% of the time was spent counseling!)

Now, there are 3 "groups" of office visit codes. What they stand for is:

99201-99205 - new patient office visits (meaning the patient has not been seen in 3 years)
99211-99215 - established patient office visits (established patients and follow up visits)
99241-99245 - consultation office visits (these are for patient referred directly to you only!!! Don't let the word "consultation" fool you - this is not simply a consult with a patient. If you use one of these 5 codes, you must have a referral from another health care professional, and you are required to send a follow up letter back to the referring professional when you use these codes. Also - this code set is only used once for the patient's initial visit, any other visits after that would fall into the established patient coding set, 99211-99215). Another thing to be aware of when using this coding set is that not all insurer accept these consultation codes anymore (if they don't, no big deal, just use the new patient office visit codes instead).

If you would like to e-mail me at courtney@dentalwriter.com i would be happy to send you the following information in charts that are a bit easier to read....

**The time spent description is under the code if you are going by time spent, the documentation requirement for each code the bullet points following.

New Patient Office Visits (must have 3 of 3 for documentation requirements)

99201
10 min face to face w/ doc - Presenting problems are self-limited or minor
•A problem focused history
•A problem focused exam
•Straightforward medical decision making
99202
20 min face to face w/ doc – Presenting problems are low to moderate severity
•An expanded problem focused history
•An expanded problem focused exam
•Straight forward medical decision making
99203
30 min face to face w/ doc – Presenting problems are moderate severity
•A detailed history
•A detailed exam
•Low complexity medical decision making
99204 45 min face to face w/ doc Presenting problems are moderate to high severity
•A comprehensive history
•A comprehensive exam
•Moderate complexity medical decision making
99205 60 min face to face w/ doc Presenting problems are moderate to high severity
•A comprehensive history
•A comprehensive exam
•High complexity medical decision making


Established patient office visits (need 2 of 3 documentation requirements)

99211 Visit may not require presence of doc, typically 5 min spent with patient
•Just do your SOAP notes
99212 10 min face to face w/ doc Presenting problems are self limited to minor
•A problem focused history
•A problem focused exam
•Straightforward medical decision making
99213 15 min face to face w/ doc Presenting problems are low to moderate severity
•An expanded problem focused history
•An expanded problem focused exam
•Low complexity medical decision making
99214 25 min face to face w/ doc Presenting problems are moderate to high severity
•A detailed history
•A detailed exam
•Moderate complexity medical decision making
99215 40 min face to face w/ doc Presenting problems are moderate to high severity
•A comprehensive history
•A comprehensive exam
•High complexity medical decision making

Consultation office visit codes (must have 3 of 3 documentation requirements)

99241 15 min face to face w/ doc Presenting problems are self limited or minor.
•A problem focused history
•A problem focused exam
•Straightforward medical decision making
99242 30 min face to face w/ doc Presenting problems are low severity
•An expanded problem focused history
•An expanded problem focused exam
•Straightforward medical decision making
99243 40 min face to face w/ doc Presenting problems are moderate severity
•A detailed history
•A detailed exam
•Low complexity medical decision making
99244 60 min face to face w/ doc Presenting problems are moderate to high severity
•A comprehensive history
•A comprehensive exam
•Moderate complexity medical decision making
99245 80 min face to face w/ doc Presenting problems are moderate to high severity
•A comprehensive history
•A comprehensive exam
•High complexity medical decision making

Hope this helps! Let us know if you have any further questions.