Office Visit

CPT:
Code	Description
99201	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
99212	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

 

SNOMED:
Code	Description
185463005	Visit out of hours (procedure)
185464004	Out of hours visit – not night visit (procedure)
185465003	Weekend visit (procedure)
30346009	Evaluation and management of established outpatient in office or other outpatient facility (procedure)
3391000175108	Office visit for pediatric care and assessment (procedure)
37894004	Evaluation and management of new outpatient in office or other outpatient facility (procedure)
439740005	Postoperative follow-up visit (procedure)

Preventive Care Services, 18 years old and Up

CPT:
Code	Description
99385	Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386	Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99387	Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
99395	Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396	Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397	Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older

Home Healthcare Services

CPT:
Code	Description
99341	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
99342	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99343	Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99344	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
99345	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
99347	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
99348	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99349	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99350	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.

 

SNOMED:
Code	Description
225929007	Joint home visit (procedure)
315205008	Bank holiday home visit (procedure)
439708006	Home visit (procedure)
698704008	Home visit for rheumatology service (procedure)
704126008	Home visit for anticoagulant drug monitoring (procedure)

Telephone Visits

CPT:
Code	Description
98966	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
98967	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
98968	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
99441	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
99442	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
99443	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

 

SNOMED:
Code	Description
185317003	Telephone encounter (procedure)
314849005	Telephone contact by consultant (procedure)
386472008	Telephone consultation (procedure)
386473003	Telephone follow-up (procedure)
401267002	Telephone triage encounter (procedure)

Online Assessment

CPT:
Code	Description
98969	Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network
98970	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
98971	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
98972	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
98980	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes
98981	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)
99421	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
99422	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
99423	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
99444	Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network
99457	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
99458	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)

 

HCPCS:
Code	Description
G0071	Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only
G2010	Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment
G2012	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
G2061	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes
G2062	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes
G2063	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes
G2250	Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment
G2251	Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of clinical discussion
G2252	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

Hospice Services is captured by having an Inpatient Encounter with a Discharge for Hospice Care, or a Hospice Encounter, or Hospice Care Ambulatory Procedure Ordered or Performed, or a Hospice Diagnosis, or a Hospice Assessment with a result of Yes, during the measure period. In order to meet the requirements for the Hospice exclusion, at least one of the aforementioned must be documented in the chart and start before or during the measurement period:

Inpatient Encounter (SNOMED) during the measurement period that ends with Discharge for Hospice Care (SNOMED)
This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

Encounter – Inpatient

SNOMED:
Code	Description
183452005	Emergency hospital admission (procedure)
32485007	Hospital admission (procedure)
8715000	Hospital admission, elective (procedure)

and

Discharge Code

SNOMED:
Code	Description
428361000124107	Discharge to home for hospice care (procedure)
428371000124100	Discharge to healthcare facility for hospice care (procedure)

 

Hospice Encounter (SNOMED or HCPCS) during or overlapping the measurement period

This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

SNOMED:
Code	Description
183919006	Urgent admission to hospice (procedure)
183920000	Routine admission to hospice (procedure)
183921001	Admission to hospice for respite (procedure)
305336008	Admission to hospice (procedure)
305911006	Seen in hospice (finding)
385765002	Hospice care management (procedure)

 

HCPCS:
Code	Description
G9473	Services performed by chaplain in the hospice setting, each 15 minutes
G9474	Services performed by dietary counselor in the hospice setting, each 15 minutes
G9475	Services performed by other counselor in the hospice setting, each 15 minutes
G9476	Services performed by volunteer in the hospice setting, each 15 minutes
G9477	Services performed by care coordinator in the hospice setting, each 15 minutes
G9478	Services performed by other qualified therapist in the hospice setting, each 15 minutes
G9479	Services performed by qualified pharmacist in the hospice setting, each 15 minutes
Q5003	Hospice care provided in nursing long term care facility (ltc) or non-skilled nursing facility (nf)
Q5004	Hospice care provided in skilled nursing facility (snf)
Q5005	Hospice care provided in inpatient hospital
Q5006	Hospice care provided in inpatient hospice facility
Q5007	Hospice care provided in long term care facility
Q5008	Hospice care provided in inpatient psychiatric facility
Q5010	Hospice home care provided in a hospice facility
S9126	Hospice care, in the home, per diem
T2042	Hospice routine home care; per diem
T2043	Hospice continuous home care; per hour
T2044	Hospice inpatient respite care; per diem
T2045	Hospice general inpatient care; per diem
T2046	Hospice long term care, room and board only; per diem

 

Hospice Care Ambulatory Procedure (SNOMED, CPT, or HCPCS) during or overlapping the measurement period
This is captured by adding a procedure with a valid SNOMED, CPT, or HCPCS code using the Procedure widget in a note.

SNOMED:
Code	Description
385763009	Hospice care (regime/therapy)
385765002	Hospice care management (procedure)

 

CPT:
Code	Description
99377	Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
99378	Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more

 

HCPCS:
Code	Description
G0182	Physician supervision of a patient under a medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more

 

Hospice Diagnosis (SNOMED) during or overlapping the measure period

This is captured by adding a diagnosis with a valid SNOMED code using the Diagnosis widget in a note.

SNOMED:
Code	Description
170935008	Full care by hospice (finding)
170936009	Shared care – hospice and general practitioner (finding)
305911006	Seen in hospice (finding)

 

Hospice Assessment overlapping the measure period

To qualify for the Hospice Assessment denominator exclusion, the patient must have a Hospice Assessment with a LOINC code of 45755-6 with a result finding of Yes, with a SNOMED code 373066001, that overlaps the measurement period.

This can be achieved by configuring a checklist with a Hospice Care checklist item, and then selecting that checklist item for applicable patients.

First, create or modify a procedure/result condition via Edit > System Tables > All Conditions.

In the Conditions Properties dialog, be sure to select the Procedure option and attach the 45755-6 code in the corresponding LOINC Code field.

Check the Result option, the 45755-6 code should also appear in the corresponding LOINC Code field.

 

Next, in the Template Editor, access the template you want to create or modify a checklist to include the Hospice Care item.

In the checklist, right click and select Insert finding…

In the Finding dialog, configure an applicable Heading; then and create Normal finding, for example Receiving Hospice Care; and then click Tag and attach the procedure/result configured above.

Click the SNOMED button and then attach the 373066001 SNOMED code to the tagged item.

After the checklist has been configured with the Hospice Care, and configured for the note template, whenever a patient is receiving hospice care, simply select this option in the checklist for the patient.

Palliative Care is captured by having a Palliative Diagnosis, or a Palliative Encounter, or a Palliative Intervention, or a Palliative Care Assessment, during or overlapping the measure period. In order to meet the requirements for the Palliative Care exclusion, at least one of the aforementioned must be documented in the chart and start before or during the measurement period:

Palliative Diagnosis (ICD10 or SNOMED) overlapping the measure period

This is captured by adding a diagnosis with a valid SNOMED or ICD10 code using the Diagnosis widget in a note.

SNOMED:
Code	Description
305686008	Seen by palliative care physician (finding)
305824005	Seen by palliative care medicine service (finding)
441874000	Seen by palliative care service (finding)

 

ICD10:
Code	Description
Z51.5	Encounter for palliative care

 

Palliative Encounter (SNOMED or HCPCS) overlapping the measure period

This is captured by adding a procedure with a valid SNOMED or HCPCS code using the Procedure widget in a note.

SNOMED:
Code	Description
305284002	Admission by palliative care physician (procedure)
305381007	Admission to palliative care department (procedure)
4901000124101	Palliative care education (procedure)
713281006	Consultation for palliative care (procedure)

 

HCPCS:
Code	Description
G9054	Oncology; primary focus of visit; supervising, coordinating or managing care of patient with terminal cancer or for whom other medical illness prevents further cancer treatment; includes symptom management, end-of-life care planning, management of palliative therapies (for use in a medicare-approved demonstration project)
M1017	Patient admitted to palliative care services

 

Palliative Intervention (SNOMED) overlapping the measure period

This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

SNOMED:
Code	Description
103735009	Palliative care (regime/therapy)
105402000	Visit of patient by chaplain during palliative care (regime/therapy)
1841000124106	Palliative care medication review (procedure)
395669003	Specialist palliative care treatment (regime/therapy)
395670002	Specialist palliative care treatment – inpatient (regime/therapy)
395694002	Specialist palliative care treatment – daycare (regime/therapy)
395695001	Specialist palliative care treatment – outpatient (regime/therapy)
433181000124107	Documentation of palliative care medication action plan (procedure)
443761007	Anticipatory palliative care (regime/therapy)

 

Palliative Care Assessment overlapping the measure period

To qualify for the Palliative Assessment denominator exclusion, the patient must have a Palliative Assessment with a LOINC code of 71007-9 that overlaps the measurement period.

This can be achieved by configuring a checklist with a Palliative Care checklist item, and then selecting that checklist item for applicable patients.

First, create or modify a procedure/result condition via Edit > System Tables > All Conditions.

In the Conditions Properties dialog, be sure to select the Procedure option and attach the 45755-6 code in the corresponding LOINC Code field.

Check the Result option, the 45755-6 code should also appear in the corresponding LOINC Code field.

 

Next, in the Template Editor, access the template you want to create or modify a checklist to include the Hospice Care item.

In the checklist, right click and select Insert finding…

In the Finding dialog, configure an applicable Heading; then and create Normal finding, for example Receiving Palliative Care; and then click Tag and attach the procedure/result configured above.

 

After the checklist has been configured with the Palliative Care option, and configured for the note template, whenever a patient is receiving palliative care, simply select this option in the checklist for the patient.

 

This is captured by:

• An electronic lab result with a valid LOINC code,
• Adding a finding with a valid LOINC code using the Checklist widget in a note,
• Adding a numeric result with a valid LOINC code using a Numeric control in a note, or
• Adding a procedure with a valid LOINC code using the procedure widget in a note.

LOINC:
Code	Description
10524-7	Microscopic observation [Identifier] in Cervix by Cyto stain
18500-9	Microscopic observation [Identifier] in Cervix by Cyto stain.thin prep
19762-4	General categories [Interpretation] of Cervical or vaginal smear or scraping by Cyto stain
19764-0	Statement of adequacy [Interpretation] of Cervical or vaginal smear or scraping by Cyto stain
19765-7	Microscopic observation [Identifier] in Cervical or vaginal smear or scraping by Cyto stain
19766-5	Microscopic observation [Identifier] in Cervical or vaginal smear or scraping by Cyto stain Narrative
19774-9	Cytology study comment Cervical or vaginal smear or scraping Cyto stain
33717-0	Cervical AndOr vaginal cytology study
47527-7	Cytology report of Cervical or vaginal smear or scraping Cyto stain.thin prep
47528-5	Cytology report of Cervical or vaginal smear or scraping Cyto stain