Question: How do I code for a patient office visit? Can I use consultation codes? What diagnosis code is appropriate for a patient office visit during which the patient is evaluated for OSA and scheduled for testing?
Answer: Patient visits are billed using evaluation and management (E/M) codes. The E/M codes are found in the CPT® code book. Office visits in particular are billed using two code ranges – for new patients, E/M codes 99201-99205 can be used; for established patients, E/M codes 99211-99215 can be used. Medicare no longer reimburses for consultation codes (E/M code range 99241-99245). However, some private payers may still reimburse for these services. Physicians should bill diagnosis code(s) that justify the service. In the case of an office visit, this may include hypersomnolence, snoring, obesity, or a range of complicating comorbidities such as hypertension. Unless the patient has been diagnosed with obstructive sleep apnea (OSA) previously, the diagnosis of OSA can’t be assigned until testing and interpretation is complete.
These recommendations may change, however, given the CMS Proposed Rule, in which CMS outlined plans to significantly modify E/M documentation guidelines, coding, and reimbursement, to align with the Patients over Paperwork initiative. The AASM expressed support for the American Medical Association’s response to CMS, which encouraged the Agency to allow the medical community to assist with revising the E/M process through the formation of a workgroup, made up of health care professionals with experience in coding, reimbursement, and clinical expertise. The Workgroup has since been convened and is working to identify solutions to the current E/M coding and payment issues and provide solutions for implementation in the 2020 calendar year.
If the coding recommendations change, an updated response to this coding question will be featured and posted to the AASM website.