CPT 99453, 99454, 99447- 99448 - guidelines updates on documentation

CMS is finalizing our proposals to pay separately for two newly defined physicians’ services furnished using communication technology,


1. Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)

2. Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)

3. Chronic care remote physiologic monitoring -CPT codes 99453, 99454, and 99457.

4. Interprofessional internet consultation - CPT codes 99451, 99452, 99446, 99447, 99448, and 99449.


Practitioners could be separately paid for the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.


This would increase efficiency for practitioners and convenience for beneficiaries. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.



E&M Documentation Changes for 2019


For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. For CY 2019 and beyond, CMS is finalizing the following policies:

1. For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.


2. Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.




New codes for professional evaluation services:

• Testing evaluation services must always be performed and reported by professional (Physician & other qualified health care professional), using codes 96130, 96131, 96132 & 96133.

* Elements of professional work in the new evaluation service codes include:
▪ Integration of patient data.
▪ Interpretation of standardized test results and clinical data.
▪ Clinical decision making.
▪ Treatment planning and report.
▪ Interactive feedback to the patient, family member(s) or caregiver(s).
• Testing evaluation services may be billed on the same or different days.
• Testing evaluation services cannot be reported by the technician


Hint: Interactive feedback- Based on patient specific cognitive and emotional strengths and weaknesses, interactive feedback may include promoting adherence to medical and/or psychological treatment plans; educating and engaging the patient about his or her condition to maximize patient collaboration in their care; addressing safety issues; facilitating psychological coping; coordinating care; and engaging the patient in planning given the expected course of illness or condition, when performed.