CPT Code 99212 – E/m Billing Guide [+Reimbursements]

Having trouble differentiating between psychiatric E/M CPT codes? Want to know more reimbursement for CPT Code 99212? Look no further! This post will provide the information you need. If you’re in need of further billing help, consider hiring a team of mental health billing experts.

CPT Code 99212: Evaluation and Management Definition

An evaluation and management appointment for an established patient in an office or outpatient setting. 

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CPT code 99211 time lengthProcedure Code 99212 Time Length

99212 is 10 minutes in length.

For clients with more complex treatment plans, a different CPT code may need to be used. If you’re having trouble billing for E/M established patients, take a look at our billing services.

CPT Code 99212: Evaluation and Management Description

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components to be present in the medical record:

  • A problem focused history
  • A problem focused examination
  • Decision making regarding treatment is straightforward

Usually, the presenting problem(s) treatment is straightforward. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

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99212 Code Billing Tip!

A good rule to use when figuring out if you should use code 99212 is to assess if the presenting problem is self-limited or minor. Additionally, make sure the visit was 10 minutes and included two of three components.

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99212 vs 99213 vs 99214 vs 99215:  Evaluation and Management CPT Code 99212

Generally, these billing codes are differentiated by amount of time spent with the patient and severity of the presenting problem. They are all part of HCPS, the Healthcare Common Procedure Coding System. Use 99212 for patients whose appointments are 10 minutes and whose treatment is considered straightforward. Other CPT code severity requirements are listed below:

  • 99212: straightforward
  • 99213: low
  • 99214: moderate
  • 99215: high

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CPT Code 99212 Reimbursement Rate

Medicare reimburses for procedure code 99212 at $46.13.

Procedure Code 99212 Reimbursement Rates – Medicare

CPT CodeService TimeRate
9921210 minutes$46.13
9921315 minutes$68.10
9921425 minutes$110.43
9921540 minutes$148.33

99212 Reimbursement Rates – Medicaid

CPT CodeService TimeRate
9921210 minutes$31.36
9921315 minutes$43.23
9921425 minutes$66.80
9921540 minutes$99.95

99212 Commercial Insurance Reimbursement Rates According to Medicare

Here are the rates that Medicare believes are the commercial insurance rates for these services (this is not the Medicare rate for 99212):

CPT CodeService TimeRate
9921210 minutes$90
9921315 minutes$90
9921425 minutes$90
9921540 minutes$148

These rates are adjusted down and reflect what Medicare has deemed are average rates for most psychiatrists across the United States.  These rates are adjusted by Medicare.

99212 Medicare Rates

Established Client Psychiatry Medicare Rates for 2019 and 2020

Some insurance companies only pay 15% over the Medicaid rate in their state, whereas others pay 45%, 60%, 80%, 85% on top of their state’s medicaid rate.

You can see these rates vary across insurance companies.  It’s important to keep this in mind when working on your mental health insurance credentialing applications.  Ask colleagues about rates if you dare, or reach out for help from us about suggestions!

Evaluation and Management Codes:  New vs Established Clients

Psychiatry codes 99212 through 99215 and 99202 through 99205 are differentiated by clients being new or established.

Unlike 99212-99215, 99202-99205 describe newly established clients being seen for evaluation and management services.  Code 99212 should only be used with established clients you have already seen.

Getting Help Billing

Is all of this gibberish?  We established a mental health billing service at TheraThink to help you stay away from all this jargon so you can focus on what you do best.  Reach out now for more information on our services.

Sources

https://www.aafp.org/journals/fpm/blogs/inpractice/entry/coding_office_visits_the_easy_way.html

http://www.medicarepaymentandreimbursement.com/2010/10/time-guideline-for-99211-99212-99213.html#:~:text=CPT%2099212%20Office%20or%20other,examination%3B%20straightforward%20medical%20decision%20making.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

https://www.palmettogba.com/Palmetto/Providers.Nsf/files/Video_Part_B_CPT-Codes-for-Evaluation-and-Management-Office-Visits-Established.pdf/$File/Video_Part_B_CPT-Codes-for-Evaluation-and-Management-Office-Visits-Established.pdf

CPT Codes 99212 and 99213: Decide Which Code to Use for Behavioral Assessment Billing

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