O U T PAT I E N T P R I M A R Y C A R E

Billing Code Reference

Preventive Visits
Age Range New Patient Established Patient

Infant, < 12 months 99381 99391

1-4 years 99382 99392

5-11 years 99383 99393

12-17 years 99384 99394

18-39 years 99385 99395

40-64 years 99386 99396

65+ 99387 99397

Welcome to Medicare (IPPE) G0402

Medicare Initial Wellness (PPPS) G0438

Subsequent Medicare Wellness (PPPS) G0439

Other Preventive Codes

Code Purpose

For patients up to age 21, use for Early & Periodic Screening, Diagnostic, and Treatment (EPSDT) services such as
S0302
developmental milestone assessments, autism screening, PEDS forms, etc.

Use for any Behavioral Health Screening such as PHQ, GAD, PSC (needs a U modifier depending on your employer type and
96110
whether need is identified)

Q0091 Pap collection. Counts as procedure so needs modifier 25

Breast/pelvic physical exam for screening of breast and cervical cancer. Must do both; counts as procedure so needs
G0101
modifier 25.

G0102 Prostate cancer screening rectal exam. Counts as procedure so needs modifier 25

Office Visits
Medical Decision Making-Based or Time-Based Billing
Note: Level 2/straightforward MDM (99202, 99212) visits should generally not be used unless billing for time.

Code Elements of MDM Time (minutes)

Level of MDM
New Established Problems Data Risk New Established

99202 99212 Straightforward Minimal Minimal/None Minimal 15-29 10-19

99203 99213 Low Low Limited Low 30-44 20-29

99204 99214 Moderate Moderate Moderate Moderate 45-59 30-39

99205 99215 High High Extensive High 60-74 40-54

Telehealth

Phone Only Video

Code Time (minutes)

99441 5-10
Bill for time or use MDM with modifier 95
to denote telehealth service
99442 10-20

99443 20-30
 Other Office Visits
Code Purpose

Transitional care management, discharged within 7 days of visit (often more complex patients/admissions).
99496
Must have documentation of phone call within 2 business days of discharge andprior to office visit.
Transitional care management, discharged within 14 days of visit (often less complexpatients/admissions).
99495
Must have documentation of phone call within 2 business days of discharge and prior to office visit.

Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to
99058 basic service. Reported when the condition of the patient requires immediate attention of the provider (eg, asthma attack,
seizure) and that provider stops what they are doing to attend to the patient.

Service(s) provided in the office at times other than regularly scheduled office hours, or days when the office is normally
99050 closed (e.g., holidays, Saturday, or Sunday), in addition to basic service. Reimbursement and times of evenings/weekends
determined by payer.
Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic
99051
service. Reimbursement and times of evenings/weekends determined by payer.

Modifiers
Code Purpose
Significant, separately identifiable evaluation & management service by same provider on same day. Use with procedures
25
done on same day as E&M visit.
Multiple procedures were performed at the same session. Use when different procedures performed at the same session;
51 or a single procedure performed multiple times at different sites; or a single procedure performed multiple times at the
same site
59 A procedure or service was distinct or independent from other non-E/M services performed on same day.

Common Office Procedures

Code Purpose
69209 Unilateral ear lavage
69210 Unilateral cerumen removal with instrumentation
17000 EKG interpretation
17002 Cryo/destruction of 1st lesion
17110 Cryo/destruction of lesions 2-14
17110 Removal of benign lesions, other than skin tags or cutaneous vascular lesions, up to 14 lesions
58300 Insertion of IUD
58301 Removal of IUD
11981 Insertion of non-biodegradable drug delivery implant
11982 Removal of non-biodegradable drug delivery implant

Counseling
Code Purpose

Vaccine Counseling
G0315 5-15 minutes, under age 21, vaccine given on same day
G0312 5-15 minutes, under age 21, vaccine not given on same day
Tabacco Counseling
99406 Intermediate level of counseling, 3-10 min
99407 Intensive level of counseling, >10 min
Health Behaviors
96156 Health behavior assessment (health-focused clinical interview, behavioral observations, clinical decision making)

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