Steps
Step 1: Is the patient NEW or ESTABLISHED?
Step 2: Calculate MDM
Step 3: Determine the Level
Step 4: Add G2211
Step 5: Use Time When Needed
Codes
E/M CPT: 99213, 99214, 99215, 99204, 99205
HCPCS (Add-on): G2211
Modifier: GC
❶ Is NEW or ESTABLISHED?
-CPT code
❷ MDM
-3 columns: problems addressed, data reviewed, and risk
❸ E/M Level
≥ 2 Low→ Low
≥ 2 Moderate→ Moderate
≥ 2 High→ High
*Not additive, so low+low+high is low
*Prescription drug management = moderate risk
❹ ⊕G2211
-HCPCS code (add-on code), cannot be billed by itself
-Always use, except:
>1x consultation only
>Independent medical examination
>Pre-op clearance visit
>You are not assuming ongoing responsibility for the condition
❺ Time
EPIC
-If fellow clinic, it is the same as resident
