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:
| 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 |
| 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 |
| 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 |
| 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