Published April 21, 2023
Outpatient Billing & Coding Guidelines for 2023: Key Types and When to Use Them
Author: Jillian Joseph, MPAS, PA-C
Billing and coding are important aspects of being a successful clinician, but unfortunately, something we often must learn on the job. Set yourself apart from colleagues and gain an understanding of billing and coding basics with the below review of how to efficiently manage medical billing and coding in the primary care outpatient setting.
Download and print our Billing Code Reference Guide to help keep track of billing codes.
Types of Billing and Coding Covered in This Post
- Medical Decision-Making
- Time-Based
- Preventive Visit
- Urgent Care
- Transitional Care Management
- After Hours
- Procedures
- Telehealt
Reframing How You Think About Billing & Coding
An Important Tool Rather than a Tedious Task
A basic understanding of billing and coding is important no matter in which type of practice you are employed. If you’re working in a fee-for-service environment, you need to effectively keep track of the patients you see and how much time you spend with them. A lot of clinicians think of billing and coding as a tedious task, but it is a useful tool–especially early in your career–to illustrate your productivity and the complexity of the patients that you are taking care of. You can also use billing and coding to help keep track of procedures that you're doing. This is helpful as you're thinking about credentialing for different procedures or adding certain skills to your toolbox.
It's important to note that you may not be responsible for billing and coding depending on where you practice. Some larger institutions or departments may have team members that handle billing and coding based on patient charts. If this is the case, a basic understanding of billing and coding is still important as you will want to ensure proper charting.
Why is effective medical billing and coding important?
- It’s an excellent tool to illustrate your productivity and the complexity of the patients that you are taking care of – something you’ll want to be sure you’re communicating effectively, especially as an early-career clinician.
- You can use billing to help keep track of procedures that you're doing, which is useful as you’re thinking about credentialing for different procedures.
- Without good records, you can easily find yourself underbilling, leading to less revenue.
Types of Outpatient Medical Billing and When to Use Them
There are two main types of outpatient medical billing in primary care – medical decision-making and time-based. Each has certain criteria patient care must meet to qualify. Below is an overview of each type and when it is best to use each.
Medical Decision-Making Billing
Outpatient Visits
| Code | Level of MDM | Time |
| |
|
|
| 99202 99212 |
Straightforward | 15-29 10-19 |
| 99203 99213 |
Low | 30-44 20-29 |
| 99204 99214 |
Moderate | 45-59 30-39 |
| 99205 99215 |
High | 60-74 40-54 |
You can bill based on medical decision-making (MDM) or time. The levels of MDM go from “straightforward” (2) all the way up to “high” (5). Each corresponds to a number, as shown in Figure 1, with most primary care visits starting at level 3 (low). New patient coding ends in a “0#,” while established patients end in a “1#.”
It’s important to remember that history and physical no longer count towards your level of service, so whatever you document needs to be medically appropriate, and you get to decide that.
Medical decision-making billing considers three categories:
- Number and complexity of the problems addressed
- Amount and/or complexity of data reviewed and analyzed
- Risk of complications and/or morbidity or mortality of the patient management option
You must meet very specific criteria in each of the three categories above to qualify for a specific level of billing. The level is also determined by the “best two out of three.” For example, if you're seeing a patient, and you have documentation to support a moderate (4) complexity in terms of problems, a low (3) complexity in terms of data, and a moderate (4) complexity in terms of risk, that means that you've satisfied two out of the three elements to get to a level 4 visit.
In the video below, we review how you would qualify for a level 3 code.
Time-Based Billing
Time-based billing allows you to bill in increments of 10 or 15 minutes of time spent with a patient. For established patients, you have 10-minute increments of time, while 15-minute increments are used for new patients. All time-based billing activities must be on the date of the patient visit.
Time includes:
- Preparing to see the patient (i.e., reviewing tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically necessary examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, and/or procedures
- Referring and communicating with other health care professionals (when not reported separately)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results and communicating results to the patient/family/caregiver (not reported separately)
- Care coordination (not reported separately)
Some of these time elements can also be billed by other healthcare team members, like nursing or care management staff. It’s important to make sure that if you are not billing for time your colleagues are also billing for.
When to Use Medical Decision-Making and Time-Based Billing
When deciding whether to use time-based billing or medical decision-making billing, you will typically decide based on the nature of the encounter. Time-based billing is appropriate when most of the time is spent counseling and coordinating care, whereas MDM billing is best for complex medical decision-making. For instance, if a patient with chronic pain requires a lengthy counseling session to discuss their treatment options, time-based billing may be used. In cases like these, you may not have enough criteria to qualify for a higher level of service, but the time spent with the patient does qualify for a higher level of service and so should be used. However, if a patient with multiple comorbidities presents with chest pain, shortness of breath, and a history of heart disease, MDM billing may be more appropriate.
Preventive Visit Billing
Preventive visits are coded by age group. There are specific codes that may be used for other purposes as outlined below.
Medicare:
When patients are eligible for Medicare, if they have Medicare A and B, then they can have a Medicare wellness visit as their annual preventive visit. For the Medicare wellness visit, there are three different options:
- Initial Visit (1st year on Medicare)
- Annual Initial Visit (2nd year on Medicare)
- Subsequent Initial Visit (3rd year and after on Medicare)
Children:
Well-child visits can also have the Early and Periodic Screening and Diagnostic Treatment (EPSDT) codes, which include behavioral and developmental screening questionnaires that are reviewed in the annual visit session.
Breast/Pelvic Cancer Screening:
Separate codes are used for breast and pelvic cancer screening exams. You should also bill separately when you collect a pap smear which counts as a procedure.
Preventive Counseling:
Preventive counseling cannot be billed during a preventive visit but can be billed during a follow-up visit if you spend a significant amount of time counseling on an unhealthy behavior, e.g., tobacco use.
When to Use:
Preventive care visit billing is appropriate when the visit is solely for the purpose of preventive care and does not include any diagnosis or treatment of a medical condition. Keep in mind that this is distinct from medical decision-making billing. However, if you address anything outside of the standard requirements of a preventive visit, you can use a separate code to capture your medical decision-making (i.e. addressing chronic conditions, medication management, etc.). These codes will often only be reimbursed yearly for all patients over the age of 1 year.
Other Types of Visits
Urgent Care
Other visit types that are important to understand are urgent care or same-day visits. You can bill a special code if the visit disrupts your other scheduled office services. For example, if you're fitting someone in at the last minute and it disrupts the rest of your schedule, you can add a special urgent care code to get a greater reimbursement.
When to Use:
Add a special urgent care code to get a greater reimbursement if you’re fitting someone in at the last minute for an urgent complaint or issue, and it disrupts the rest of your schedule. This is used in addition to the regular E&M level of service.
Transitional Care Management
Transitional care management codes are for patients who have recently been admitted to the hospital. This is a 30-day billing period that starts on the day of discharge. There are very specific criteria the patient must meet to qualify for this billing code.
- Patients must have had a phone call, from the discharging institution of your office, within 2 days of discharge.
- The patient must be admitted through the emergency department for an acute issue.
You can do a 7-day transitional care code or a 14-day transitional care code, meaning that you've seen the patient for a follow-up visit within 7 days of their discharge or within 14 days of their discharge. If the patient gets readmitted to the hospital within the 30-day billing period, but you're not able to do another transitional care visit for that patient within that 30-day window.
When to Use:
When a patient has been recently discharged from the hospital for any reason other than an elective hospitalization or surgery, there has been a phone call made to the patient within 2 days of discharge, and you are seeing them within 7 or 14 days of discharge.
After Hours
When you see patients outside of your regularly scheduled hours, you can utilize after hours billing. You may also count regularly scheduled hours that are on evenings or weekends or holidays. Remember that individual payers set the “regularly scheduled hours,” and not every payer recognizes these codes.
When to Use:
Use After Hours billing when you see a patient outside of regularly scheduled hours including evenings, weekends, or holidays.
Procedures
Procedures can be billed as part of a regular visit. If you have a patient who comes in with a suspicious lesion, and you decide to do a biopsy as part of that visit, you can bill for the visit itself, (I.e., evaluation of the situation) and then you also bill for the procedure using the 25 modifier to signify a separately identifiable service.
Alternately, if the same patient comes in and you decide to evaluate the lesion, but they come back next week at another time for the actual procedure, you can only bill for the procedure at their return visit. You would not add another evaluation and management code because you've already done that during the previous visit.
Remember that EKG interpretation, Pap smear collection, and breast and pelvic exams performed for screening of breast or pelvic cancers count as procedures.
When to Use:
When you are performing a procedure, with or without an additional E&M level of service code.
Telehealth
If you are billing for a telehealth phone-only visit you will bill for time in five-minute increments. You want to make sure you're using a 95 modifier to identify that it's a telehealth visit. Modifiers are for a significant separately identifiable evaluation and management service by the same provider on the same day.
If it's a video visit, then you use a regular E&M (Evaluation and Management) code, like a level 3, 4, or 5, but also with that telehealth modifier.
When to Use:
Use telehealth billing when billing for a telehealth phone-only visit.
Billing is complex and there’s a lot to unpack, but it's important for you to keep track of your work while you're in visits with patients. To help you keep the codes straight, download our Billing Code Reference Guide.
For more strategies to build confidence in the office visit as an early-career clinician, enroll in Primary Care Bootcamp for NPs and PAs.