Adult Current Procedural Terminology®
Coding Case Scenarios
Background
In an effort to address the continuing problem of administrative burden for physicians in nearly every
specialty, recent changes to the Evaluation and Management (E/M) office visit Current Procedural
Terminology (CPT®)1 codes (99201-99215) code descriptions and documentation standards have
been approved for use by the American Medical Association (AMA) and are finalized in the 2020
Medicare Physician Fee Schedule Final Rule, effective 2021. These new codes, effective January 1,
2021, are designed to be more intuitive and reduce administrative burden by removing complex
counting systems for history, exam and data.2 A chart of the codes prior to the change relative to the
current change is provided in Appendix 1.
The revisions relevant to documenting an immunization office visit are based on a simplification of
the guidelines, which allow for the use of “Total Time” or the use of “Medical Decision Making”3 as
key contributing factors, for the basis of payment for vaccination counseling and administration.
Coding based on time is well suited for immunization counseling as there is often low medical
decision making involved for implementing Advisory Committee on Immunization Practices (ACIP)
recommendations. The definition of time, under these new revisions, is total time, not typical time,
and represents total physician/qualified health profession (QHP) time on the date of service. The use
of date-of-service time allows for the billing of work involved in non-face-to-face services like care
coordination and review of immunization records.
The code level selection process has changed in common immunization-related scenarios from
previous documentation standards for history and physical in level selection. Under the 2021
guidelines:
1. Although a medically necessary history and exam should be performed as appropriate, only
medical decision-making or time may be used to select the level of service performed.
2. The time requirements have changed in that, rather than face-to-face time with the patient,
the physician’s total time on the date of the encounter is summed.
The new codes, which now allow for billing total time, seek to decrease administrative burden of
documentation and coding while ensuring payment for E/M is resource-based. For a complete
description of the code changes, and numerous educational modules, see the American Medical
Association website (www.ama-assn.org/cpt-office-visits).
The following case studies are designed to provide guidance on appropriate coding and billing for a
range of scenarios for providers who care for adults.
1 CPT© Copyright 2019 American Medical Association. All rights reserved. AMA and CPT are registered trademarks of the American
Medical Association.
2 American Medical Association. CPT© Evaluation and Management. www.ama-assn.org/cpt-evaluation-and-management
3 The medical decision-making components for the revised office visits can be found at www.ama-assn.org/system/files/2019-06/cpt-
revised-mdm-grid.pdf . The subject of this brief is about the coding relative to use of “total time”
PAGE 1
CASE 1
OFFICE VISIT: Low complexity, vaccine counseling with no vaccine administration
A 48-year old patient with private insurance visits his provider for his annual comprehensive health
and wellness visit, which includes a review of patient past medical history, an annual physical exam,
and coordination of follow-up monitoring of high cholesterol and pre-diabetes. This patient is an
established patient and is indicated for an influenza vaccine and a tetanus, diphtheria, pertussis
(Tdap)/ tetanus and diphtheria (Td) booster.
The physician spends 5 minutes prior to the visit, on the date of encounter, reviewing the patient’s
history, including looking for prior immunizations for this patient in the state immunization
information system (IIS). At the visit, the provider counsels the patient on the booster
recommendation and the importance of annual influenza vaccination. The patient decides not to get
either vaccine. The total time spent on the encounter lasts 35 minutes (30 minutes visit and 5
minutes of work prior to the visit).
Item Coding CPT Code Comment
Established Patient Preventive 99396 age 40–64 For cholesterol and pre-diabetic condition
Medicine Services Visit and vaccine counseling (35 min)
No additional billing for counseling
Explanation of code selection
Because no vaccine was administered, vaccine administration codes cannot be used for vaccine
counseling. The correct code is the preventive visit code which is linked to age [99395 (age 18-39),
99396 (age 40-64), 99397 (age 65 and older)]. No specific times are associated with this code.
Because these codes are not time-based, no changes are required relative to the AMA changes.
Under the new coding rules, the non “face-to-face” time spent on the date of the encounter can
be counted regardless of the fact that the total time results in the same code being previously
chosen (i.e., the time calculation has changed.)
CASE 2
PREVENTIVE VISIT: With separately identifiable E/M performed, vaccine counseling with no
vaccine administration
A 30-year old patient with private insurance makes an appointment for her annual comprehensive
preventive visit and to request a hepatitis B vaccination in order to comply with new employee
requirements. This patient is an existing patient and is indicated for hepatitis B given low titers upon
laboratory results. At the visit the provider conducts a comprehensive preventive exam and counsels
the patient on age-appropriate screening labs and tests that the patient should consider. The patient
is also diabetic, but stable. The physician provides appropriate counseling on properly managing the
patient’s diabetes.
Following counseling on the vaccine, the patient changes her mind after seeing on the employee
health form that the hepatitis B vaccination is optional. The physician spent 15 minutes counseling
the patient. As part of the visit, the patient complains of lower abdominal pain. A medically
necessary physical exam is performed, and a diagnosis is reached. The physician prescribed
medication and counsels the patient on risks and benefits. Following the face-to-face visit, the
physician enters documentation into the electronic health record. The total time on the date of the
encounter related to the additional office visit is 25 minutes.
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Item Coding CPT Code Comment
Established Patient 99395 age 18-39 For vaccine counseling (15 min)
Preventive Services Visit
Established Patient Office 99213-25: 20-29 minutes of For complaint of lower abdominal
or Other Outpatient total time spent on the date pain. Using the E/M modifier to
Services for the evaluation of encounter. Requires a the office visit because of the
and management of an medically appropriate history separately identifiable E/M
established patient and/or exam. performed (25 min) given the
primary visit was preventive.
Explanation of code selection
Because there is a separately identifiable evaluation and management service performed, the
claim would include the preventive counseling CPT code (for the discussion on hepatitis B
vaccination) plus a code for an office visit (for the complaint of lower abdominal pain). You would
append the CPT code for the office visit (99213) with modifier 25 (Separately Identifiable E/M
Service), not the preventive visit code. The CPT code 99213 is the correct choice as the time spent
on the date of the encounter falls in the range for 99213 (20-29 minutes). The 25 modifier
represents a distinct service, over and above what is included in the procedure code (vaccine
administration). If the problem visit E/M service had not been performed, modifier 25 would be
appended to the Preventive visit (99395).
The preventive counseling code (99401) was not used in this case because the service provided
around immunizations is captured in the Preventive Visit code (99395), which includes patient
specific counseling along with a patient specific history and exam and the option to order lab and
diagnostic procedures. Some payors will not pay for two E/M codes during the same encounter.
Practices should verify payer policy on E/M payment for two E/M services before reporting both
services. The total time results in the same code as prior to the change in coding rules, though the
method in which time is calculated is different.
NB: If the patient accepted hepatitis B vaccination, then the additional codes would include:
Item Coding CPT Code Comment
Immunization Administration for Vaccines/Toxoids 90471 Administration Fee
Hepatitis B vaccine, adult dosage, 3 dose-schedule, for 90746 Product Fee
intramuscular use
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CASE 3
OFFICE VISIT: Vaccine counseling with shared clinical decision-making, vaccine administered
A 28-year-old female is at her physician’s office for an asthma-related matter and to get a refill on
birth control. She and her physician discuss the human papilloma virus (HPV) vaccine and reasons
why she should complete the vaccination series. The patient has significant concerns about the
vaccine, as she recently viewed a Facebook post about negative side effects. Vaccine counseling
consumes a large proportion of the visit. The patient receives the HPV vaccine. Her total visit time on
the date of the encounter was 60 minutes.
Item Coding CPT Code Comment
Established Patient Office or 99215-25: 40-54 minutes of total For Asthma
Other Outpatient Services for time spent on the date of
the evaluation and management encounter. Requires a medically
of an established patient appropriate history and/or exam.
Prolonged Service 99XXX4- each 15 minutes, beyond (Bill 1 unit: 15 min)
99215 Vaccine Counseling
Immunization Administration for 90471 Administration Fee
Vaccines/Toxoids
HPV Vaccine, 2 or 3 dose- 90651 Product Fee
schedule, for intramuscular use
Explanation of code selection
The correct billing for this service would include the CPT E/M office visit code 99215, with a time
range of 40-54 minutes. In addition, because the total time on the date of the encounter was 60
minutes, a prolonged services code is appropriate. One unit of 99XXX (15 minutes) would be
added to the base time of the 99215 code (i.e. 40 minutes). Therefore, at 60 total minutes, a
prolonged services code 99XXX can be reported. A separate E/M service was provided in this
situation in addition to the procedure, so modifier 25 would be appended to the E/M code (99215)
because vaccine administration is considered a procedure. Since the vaccine was administered, the
administration code (90471) and the vaccine code (90651) are billed. Because of new coding rules
one unit (15 min) of a prolonged services code can be used.
CASE 4
OFFICE VISIT: Return visit for vaccination with series, with separately identifiable E/M
The 28-year old female from Case 3 returns to her physician’s office 2 months later for the second of
her series of three HPV vaccines. During the visit, she reports dysuria. A medically appropriate
history and exam are completed. The physician orders a urinalysis. The urinalysis result shows a
urinary tract infection (UTI). The physician prescribes antibiotics and provides counseling regarding
prevention of future UTIs. Prior to leaving, the patient also receives her HPV vaccine. The physician
enters documentation of clinical information into the electronic health record, including her
immunizations. The physician’s total time on the date of the encounter was 30 minutes.
4
As this is a new CPT code, the AMA will not issue the official CPT code number until the official CPT code license file is
released on or near August 31, 2020.
PAGE 4
Item Coding CPT Code Comment
Established Patient Office or 99214-25: 30-39 minutes of total Payment for
Other Outpatient Services for time spent on the date of separately
the evaluation and management encounter. Requires a medically identifiable E/M.
of an established patient appropriate history and/or exam.
Immunization Administration for 90471 Administration Fee
Vaccines/Toxoids
HPV Vaccine, 2 or 3 dose 90651 Product Fee
schedule, for intramuscular use
Explanation of code selection
The correct E/M office visit is 99214, as the time on the date of the encounter falls within the
appropriate time range (30-39 minutes). Since the vaccine was administered, the administration
code (90471) and the vaccine code (90651) are billed. A separate E/M service was provided in this
situation in addition to the procedure, so modifier 25 would be appended to the E/M code.
NB: If the patient comes back for the final HPV vaccine at the indicated time interval according to
the ACIP guidelines (6 months after initial dose and 5 months after the second dose) and receives
the vaccination as a nurse only visit with no counseling involved, this visit is coded as a vaccine
only visit, as no E/M service was documented.
Item Coding CPT Code Comment
Immunization Administration for 90471 Administration Fee
Vaccines/Toxoids
HPV Vaccine, 2- or 3-dose schedule, for 90651 Product Fee
intramuscular use
CASE 5
OFFICE VISIT: Return E/M visit and extensive vaccine counseling, no vaccine administration
A 53-year-old female returns to her primary care physician’s office for follow-up for diabetes and
HbA1C recheck, efficacy of current blood pressure control regimen (patient has primary
hypertension), and lab testing to assess appropriateness of thyroid hormone replacement dosing. A
medical problem-focused history and exam are completed. During the visit, the patient reported
that, while receiving her annual flu shot at a drugstore clinic the previous month, she became aware
of the potential need for revaccinations for some vaccines and new vaccines given her diagnosis of
diabetes. The patient had numerous concerns about what vaccines she should consider obtaining,
given her specific vaccination history/timing, and whether having had certain illnesses earlier in life
made a difference in the need for additional vaccinations. The physician spends significant time (40
minutes) reconstructing and reviewing the patient’s vaccination history, which consisted of both
electronic and non-electronic records (traveler’s vaccination books, paper records from her college
health clinic) as well as recollections from the patient’s memory; reviewing vaccination timing (and,
in some cases, the type of vaccine administered) against the known list of potential revaccinations;
and recalling the incidence and specific timing of such diseases such as measles, chickenpox and
shingles, and other evidence of immunity.
Following the review and consultation, the patient decides to take additional time to ‘think it over’;
no vaccine is administered. The physician enters clinical documentation into the electronic health
record. The physician’s total time on the date of the encounter was 70 minutes.
PAGE 5
Item Coding CPT Code Comment
Established Patient Office or 99215: 40-54 minutes of total Office visit for E/M
Other Outpatient Services for time spent on the date of
the evaluation and encounter. Requires a medically
management of an appropriate history and/or
established patient exam.
Prolonged Services 99XXX - each 15 minutes, Bill 2 units for extensive
beyond 99215 counseling
Explanation of code selection
The correct billing for this service would include the CPT E/M office visit code 99215, with a time
range of 40-54 minutes. In addition, because the total time on the date of the encounter was 70
minutes, a prolonged services code is appropriate. A unit of 99XXX (15 minutes) would be added
to the base time of the 99215 code (i.e. 40 minutes). Therefore, at 70 total minutes, two units of
the prolonged services code 99XXX would be reported.
The new coding rules allow for use of prolonged services codes to account for the additional time
spent counseling using the 99215 base of 40 minutes + 15 minutes (for first additional unit of
99XXX) +15 minutes (for second additional unit of 99XXX) = 70 minutes. The range is designed to
show the full range until one would bill the next unit of a code.
CASE 6
OFFICE VISIT: Return E/M visit, Medicare Beneficiary, Vaccine Administered
A 65-year old female Medicare beneficiary returns to her primary care physician’s office for follow-
up for diabetes and HbA1C recheck and her ACIP-recommended pneumococcal polysaccharide
vaccine, 23-valent (PPSV). The physician spends 25 minutes discussing her diabetes care and
reviewing the patient’s vaccination history.
Item Coding CPT Code Comment
Established Patient Office or Other 99213-25: 20-29 minutes of Payment for
Outpatient Services for the total time spent on the date separately
evaluation and management of an of encounter. Requires a identifiable E/M.
established patient medically appropriate
history and/or exam.
Medicare Administration Code G0009 used with Diagnosis Administration Code
Code: Z23 (rather than
equivalent CPT code 90471)
Pneumococcal polysaccharide 90732 Product Fee
vaccine, 23-valent (PPSV23), adult or
immunosuppressed patient dosage,
when administered to individuals 2
years or older, for subcutaneous or
intramuscular use
PAGE 6
Explanation of Code Selection
The correct E/M office visit is 99213, as the time on the date of the encounter falls within the
appropriate time range (20-29 minutes). A separate E/M service was provided in this situation in
addition to the procedure (G0009), so modifier 25 would be appended to the E/M code.
Since the vaccine was administered, the administration code (G0009) and the vaccine code
(PPSV23) are billed for the Medicare beneficiary. Guidance for billing Medicare Part B can be found
at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/qr_immun_bill.pdf
VACCINATION SCENARIOS THAT FALL OUTSIDE OF OFFICE VISIT CODING
CASE A: Pregnant Patient Visit with Vaccination
A pregnant 28-year old patient on Medicaid is indicated for both influenza and Tdap vaccination.
The provider spends an extraordinary amount of time (30 minutes) with the patient on vaccine
counseling. The patient ultimately decides to vaccinate. The total visit time is 45 minutes.
Except for Medicaid* as a payor, pregnancy in most cases is billed under a global fee. The global
maternity fee encompasses maternity-related services performed by all providers in
uncomplicated maternity cases. The global fee includes the treatment of routine gynecological
conditions during scheduled prenatal visits, typically 13 routine antepartum visits, delivery, and
the six-week postpartum visit and is not billed to insurance until after delivery. Any lab work,
ultrasounds, and additional or unrelated visits are billed separately.
Administration of the vaccine and the vaccine product, if provided, should be reported
separately for both Medicaid and commercial insurers. These services are not valued into the
global obstetrics package. Services such as immunization counseling may be included in the
global pregnancy fee as part of the general antepartum service for a pregnant patient for a
commercial insurer's patient since some commercial payers define the global differently than
CPT. CPT does not include these services in their definition of the global obstetrics package.
* Medicaid programs vary greatly in their requirements for billing pregnancy services. Check
with specific Medicaid carriers with instructions on how to bill for immunization services.
Explanation of code selection
Because this is a routine antepartum visit, there is no additional coding included for the
office visit, and the new coding revisions do not apply.
CPT Global Obstetric Package
CPT's global obstetric package includes all the services normally provided in uncomplicated
maternity cases (antepartum care, delivery, and postpartum care). These services are considered
bundled and are therefore not coded or reimbursed separately. Most private payers follow CPT's
obstetric package definition, but some have developed their own rules. Physicians should check
with their individual payers about how to report these services.
CONTINUED ON NEXT PAGE
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CPT Global Obstetric Package
CPT's global obstetric package codes are:
* 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without
episiotomy, and/or forceps] and postpartum care)
* 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum
care)
* 59610 (routine obstetric care including antepartum care, vaginal delivery [with or without
episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery)
* 59618 (routine obstetric care including antepartum care, cesarean delivery and postpartum
care, following attempted vaginal delivery after previous cesarean delivery)
The global obstetric codes INCLUDE:
Antepartum services (approximately 13 visits):
* the initial and subsequent history * physical examinations * recording of weight, blood
pressure, and fetal heart tones * routine urine dipstick analysis * monthly visits up to 28 weeks
gestation * biweekly visits up to 36 weeks gestation * weekly visits from 36 weeks gestation
until delivery
Delivery services:
* admission to the hospital *admission history and physical examination *management of
uncomplicated labor * vaginal or cesarean delivery
Postpartum services (traditionally 6 weeks; 90 days for Medicare for a cesarean delivery):
* Routine hospital visits * Routine office visits during global period
The global obstetric codes DO NOT INCLUDE:
Antepartum services: * Treatment of complications requiring additional services or more than
the usual 13 visits (e.g., gestational diabetes, pre-eclampsia, hyperemesis, observation for
preterm labor) * All medically indicated laboratory examinations except a routine chemical urine
analysis (e.g., obstetric panel, pregnancy test, and Pap test) * All medically indicated evaluation
procedures (e.g., ultrasound examinations, biophysical profiles, fetal non-stress tests or
amniocentesis) * Treatment for other conditions during the pregnancy (e.g., vaginitis, sinusitis or
urinary tract infection)
Delivery services: * Hospital admission services of more than 24 hours duration for a patient that
is admitted and subsequently discharged from the hospital prior to delivery. * Hospital care that
is distinct from labor or delivery and rendered up to, but not including, the day of delivery *
Treatment for medical problems complicating the management of labor and delivery requiring
additional services * Treatment of surgical complications of pregnancy (e.g., an appendectomy
or an ovarian cystectomy)
Postpartum services: * Complications requiring other services or visits during the postpartum
period
NB: The issues around additional and separate payment for vaccine counseling and vaccination
are outside the scope of this brief and therefore not covered.
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CASE B: Medicare beneficiary at Annual Wellness visit
A 72-year old Medicare beneficiary is at her annual wellness visit (AWV) and is indicated for
influenza, herpes zoster, and pneumococcal vaccines. The beneficiary receives all three vaccines.
Influenza and pneumococcal vaccinations are billed under Medicare Part B and herpes zoster
vaccination is billed under Medicare Part D. The visit lasts 25 minutes.
Explanation of code selection
In this visit the AWV is not considered an office visit, therefore new coding revisions do not
apply. Coding remains unchanged.
We ask that organizations link to the NAIIS
(www.izsummitpartners.org) on their respective
websites. If you have any questions, please contact
L.J Tan (lj.tan@immunize.org) or Angela Shen
(angela.shen@immunize.org)
PAGE 9
Appendix 1: Summary of CPT code differences for Office Visit E/M Codes (2020 compared with 2021)
New Patient Visits
2020 Medical Face-to- 2020 2021 Medical 2021
Total
CPT Code Description1 Decision Face Work CPT Code Description Decision Work
Time
Code1 Making Time RVUs Code Making RVUs
99201 Office or other outpatient visit, new, problem-focused Straight- 10 mins 0.48 99201 Deleted Code Deleted N/A Code
history & exam forward deleted
99202 Office or other outpatient visit, new, expanded problem- Straight- 20 mins 0.93 99202 Office or other outpatient visit, new, which requires a Straight- 15-29 0.93
focused history & exam forward medically appropriate history and/or examination forward
99203 Office or other outpatient visit, new, detailed history & Low 30 mins 1.42 99203 Office or other outpatient visit, new, which requires a Low 30-44 1.60
exam medically appropriate history and/or examination
99204 Office or other outpatient visit, new, comprehensive Moderate 45 mins 2.43 99204 Office or other outpatient visit, new, which requires a Moderate 45-59 2.60
history & exam medically appropriate history and/or examination
99205 Office or other outpatient visit, new, comprehensive High 60 mins 3.17 99205 Office or other outpatient visit, new, which requires a High 60-74 3.50
history & exam medically appropriate history and/or examination
1 The full description of the CPT codes can be found in the AMA-CPT Professional code book/ 2 both the 99201 and 99202 codes are low-level visit codes whereby medical decision making is straightforward and did not
change; however, the total time allocated for this code change to a range (for 99202). In the subsequent cose 99203-99205 total time changed as well as the relative value unit associated with the respective codes.
Established Patient Visits
2020 Medical Face-to- 2020 2021 Medical 2021
Total
CPT Code Description1 Decision Face Work CPT Code Description Decision Work
Time
Code1 Making Time RVUs Code Making RVUs
99211 Office or other outpatient visit, established, minimal N/A 5 mins 0.18 99211 Office or other outpatient visit, established, that may not N/A N/A 0.18
presenting problem require the presence of a physician or other qualified
health care professional. Usually, the presenting
problem(s) are minimal
99212 Office or other outpatient visit, established, problem- Straight- 10 mins 0.48 99212 Office or other outpatient visit, established, which Straight- 10-19 0.70
focused history & exam forward requires a medically appropriate history and/or forward
examination
99213 Office or other outpatient visit, established, expanded Low 15 mins 0.97 99213 Office or other outpatient visit, established, which Low 20-29 1.30
problem-focused history & exam requires a medically appropriate history and/or
examination
99214 Office or other outpatient visit, established, detailed Moderate 25 mins 1.50 99214 Office or other outpatient visit, established, which Moderate 30-39 1.92
history & exam requires a medically appropriate history and/or
examination
99215 Office or other outpatient visit, established, High 40 mins 2.11 99215 Office or other outpatient visit, established, which High 40-54 2.80
comprehensive history & exam requires a medically appropriate history and/or
examination
Source Notes: As noted in the above table for “New Patient Visits,” the change in coding for “Established Patient Visits” is in total time, which has been extended to a range of time. N/A – Not required for level selection
because it is a minimal visit of 5 minutes or less. The change deletes the 5 min total time description because the visit is inherently a minimal visit (e.g., blood pressure check). Additionally, except for 99211, the RVUs
associated with each CPT code (99212–99215) have increased. The medical decision-making components for the revised office visits can be found at www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.
RVU = Relative Value Units
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