99212

Office or Other Outpatient Visit for an Established Patient, Level 2

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 must be spent on the date of the encounter. The presenting problem(s) are typically self-limited or minor.

Clinical Indications

  • Routine follow-up for stable, well-controlled chronic conditions (e.g., stable essential hypertension, controlled type 2 diabetes without complications).
  • Management of acute, self-limited or minor illnesses (e.g., common cold, mild allergic rhinitis, minor contusion, uncomplicated headache).
  • Medication refill or adjustment for a stable condition, without significant changes in patient status or complexity.
  • Brief assessment of a single, uncomplicated new problem (e.g., minor rash, insect bite).
  • Review of diagnostic test results for a self-limited or minor condition, requiring minimal interpretation or management decisions.

Procedure Steps

  1. **For Medical Decision Making (MDM) based selection:**
  2. 1. **Number and Complexity of Problems Addressed:** Requires minimal problems, typically self-limited or minor (e.g., one self-limited or minor problem).
  3. 2. **Amount and/or Complexity of Data to be Reviewed and Analyzed:** Requires minimal or no data (e.g., no data reviewed or ordered).
  4. 3. **Risk of Complications and/or Morbidity or Mortality of Patient Management:** Requires minimal risk (e.g., conservative management, minor surgery with no identified risk factors, OTC medications).
  5. **For Time-based selection:**
  6. 1. Reviewing prior documentation and preparing for the patient encounter.
  7. 2. Obtaining interval history and/or performing a medically appropriate physical examination.
  8. 3. Counseling and educating the patient and/or family.
  9. 4. Ordering or prescribing medications, tests, or procedures.
  10. 5. Referring or communicating with other health care professionals (when not separately reported).
  11. 6. Documenting the clinical information in the electronic health record or other patient record.
  12. 7. Independent interpretation of results (when not separately reported and when appropriate).
  13. 8. Care coordination (when not separately reported).

Coding Guidelines

  • **2021 E/M Guidelines:** For office or other outpatient E/M services (99202-99215), the level of service is determined based on either the Medical Decision Making (MDM) level OR the total time personally spent by the physician or other qualified healthcare professional (QHP) on the date of the encounter.
  • **Medical Decision Making (MDM):** 99212 requires straightforward MDM. This involves minimal number and complexity of problems, minimal or no data review, and minimal risk of complications.
  • **Time Threshold:** If selecting based on time, the total time spent on the date of the encounter must be 10-19 minutes. This includes both face-to-face and non-face-to-face time directly related to the patient's care.
  • **Documentation:** The medical record must clearly support the level of MDM or the total time spent to justify the selection of 99212. Documentation should reflect the nature of the presenting problem(s) and the work performed.
  • **Established Patient Definition:** An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice within the past three years.
  • **Modifier -25:** If a significant, separately identifiable E/M service (like 99212) is performed on the same day as a minor procedure, modifier -25 must be appended to the E/M code to indicate that it was a distinct service.

Associated ICD-10 Codes