• Margaret Curtis, MD

Work Smarter, Not Harder: Coding Routine Visits

Routine visits pretty easy to code, bless 'em. Just pick the right category and you're done.

Except you might be missing all the additional work you are doing for your routine visits. For example:

-applying fluoride varnish (99188)

-scoring and documenting MCHAT (96110) or PHQ9 (96127) tests

-chart review (99354 and 99358)

-transitions of care (99495 and 99496)

Your state Medicaid and private insurers may disallow some of these, or may require a modifier like -25 or -59.

You can also bill for acute care that you perform during routine visits. The additional care must be medically necessary: usually this means something a patient would have made a separate office visit for. You have to include documentation for both the routine and acute care in your note - for example, all your usual physical exam points plus 2-7 for the acute visit. You may also need to “unbundle”, or separate out, the preventive care and acute care services you provide during the same visit.

You “unbundle” services by attaching a modifier to one of the codes. The modifier provides additional information and signals that the additional service you provided was significant and separate from the routine visit. The most commonly used modifier in primary care is -25, which separates routine care from the separate care give for the acute issue. Attach modifier -25 to the routine care code (most EMRs have a drop-down menu or check box for modifiers).

In general, the highest you can code in addition to a routine visit is a level 3 (99213 or 99203) because you can't document enough separate PE and ROS points to justify anything higher. You also can't bill for time spent to justify any level of acute care, because a certain amount of time is already assigned to a routine visit.

Some insurance will pay for both acute and routine care in the same visit, in which case your patient may be happy to have only one one trip to your office and one co-pay. If insurance won't cover these two codes together, patients may prefer to have two separate visits, one for routine care and another to address additional issues. It's worth bringing this up with your patients before addressing their "oh and by the way" concerns during a routine visit, so they won't be surprised when they get their bill for services.

Coding is complex - so much so that even professionals can get lost in the intricacies - but you only have to learn a small segment. If you can give yourself a raise, or more clout in your workplace, by learning these steps then the time spent will be worth it.

More resources:


Coding for Pediatric Preventive Care 2018

Coding for Medical Home Visits

Specific Criteria Must Be Met To Use Prolonged Service Codes

Confessions of a Pediatric Practice Management Consultant


Four Coding and Payment Opportunities You Might Be Missing

Are You Getting Paid for Non-Face-to-Face Prolonged Care

Understanding When to Use Modifier -25

Should You Modify Your Use of Modifiers?

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