Outpatient Parkinson's Disease Case Studies

Outpatient E/M Case Studies

Compare case studies of a patient with Parkinson's Disease at varying visit levels to better understand code selection for outpatient office encounters under the revised guidelines for 2021.


75-Year-Old Male with Parkinson's Disease

Total Time* for Outpatient E/M in 2021

Refer to the following tables for correct code selection when billing based on time for outpatient E/M Services:

Total Time for Outpatient E/M
  CPT Code Time (Minutes)
New Patient 99202
99203
99204
99205
15-29
30-44
45-59
60-74
Established Patient 99212
99213
99214
99215
10-19
20-29
30-39
40-54

*Total time includes non-face-to-face time on the date of service


level 3 established patient (99213)

Six month follow-up visit, in the last few months, he has been stable, tremor unchanged, no postural instability, sleep is good, and no falls: pt is Spanish speaking, primary caretaker recently diagnosed with cancer.

  • Pre-Visit: Reviewed his last f/u note with you, PCP notes, physical therapy notes for gait training exercises [3 MINS]
  • Visit: You obtain a history from the patient, asking about sleep, ambulation, overall function, doing a focused exam [20 MINS]
  • Post-Visit: Document his visit [2 MINS]

Problems Addressed Data Reviewed Patient Management Risk of Complications
1 stable chronic illness Review of PCP notes, PT notes Prescription drug management
Low Limited Moderate

View MDM table for Parkinson's Disease - 99213

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 25 minutes

Established patient, level 3 = 20-29 minutes

CPT 99213

 

Problems addressed: Low

Data reviewed: Limited

Risk of complications, M/M: Moderate

Level 3: Low

CPT 99213


level 4 established patient (99214)

A six-month follow-up visit, in the last few months, he has developed worsening gait, tremors, on carbidopa-levodopa TID; after primary caregiver hospitalized pt non-compliant with meds (unable to read patient instructions/office visit summary)

  • Pre-Visit: Reviewed your prior clinic note with exam from 6 months ago, PCP note regarding any mood symptoms over the past 6 months [3 MINS]
  • Visit: You do a brief exam, focused on tremor, rigidity, bradykinesia, postural instability, treatment options, and counseling [20 MINS]
  • Post-Visit: Document encounter [3 MINS]

Problems Addressed Data Reviewed Patient Management Risk of Complications
One chronic illness with progression Review of your note, PCP notes Prescription drug management
Moderate Limited Moderate

View MDM table for Parkinson's Disease - 99214

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 26 minutes

Established patient, level 3 = 20-29 minutes

CPT 99213

 

Problems addressed: Moderate

Data reviewed: Limited

Risk of complications, M/M: Moderate

Level 4: Moderate

CPT 99214


level 5 established patient (99215)

Six-month follow-up visit, in the last few months, he has developed worsening memory loss, primary caregiver now reporting pt wandering out of the house.

  • Pre-Visit: Reviewed PCP notes, independently review head CT, review lab results, neuropsych testing results [5 MINS]
  • Visit: You obtain a history from the patient, discuss details about his memory loss, do a MOCA exam, brief physical exam, treatment, and counseling regarding initiation of donepezil, health care proxy, and goal of care [40 MINS]
  • Post-Visit: Document encounter including testing results [4 MINS]

Problems Addressed Data Reviewed Patient Management Risk of Complications
One chronic illness with severe progression

Review PCP notes, labs, and neuropsych testing

Independent historian

Independent review of head CT

Prescription drug management
High Extensive Moderate

View MDM table for Parkinson's Disease - 99215

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 49 minutes

Established patient, level 5 = 40-54 minutes

CPT 99215

 

Problems addressed: High

Data reviewed: Extensive

Risk of complications, M/M: Moderate

Level 5: High

CPT 99215

Disclaimer:The billing and coding information provided by the American Academy of Neurology and its affiliates (collectively, “Academy”) are assessments of clinical information provided as an educational service. The information (1) is not clinical advice; (2) does not account for how private payers cover and reimburse procedures or services*; (3) is not continually updated and may not reflect the most current clinical information (new clinical information may emerge between the time information is developed and when it is published or read); and (4) is not a substitute for the independent professional judgment of the treating provider, who is responsible for correctly coding procedures and services.

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*The Academy recommends always checking private payer policies before rendering procedures or services