Outpatient physician billing, done by specialists
The professional claim for the ambulatory patient. Office and outpatient visits, observation care, and preventive services coded to the level the documentation supports, with modifiers that hold up.
The revenue is in the documentation, not the visit.
Since 2021 office and outpatient levels are set by medical decision making or total time, not history and exam. Code by habit and you either leave money behind or invite a recoupment.
- 01
Level chosen by MDM or total time
The 2021 office-visit revisions moved leveling onto medical decision making or total time. We code to what the note supports, and tell you when the note does not support it.
- 02
Modifier discipline
Modifier 25 on a same-day E/M with a procedure is one of the most audited constructs in outpatient billing. We use it where the record justifies it, and document why.
- 03
Preventive and problem visits together
A preventive visit and a problem-oriented visit on the same day are both billable when the work is distinct. Most practices bill one and lose the other.
- 04
Telehealth rules move, per payer
Place of service, modifiers, and audio-only coverage differ by payer and keep changing. We keep a payer-by-payer grid so claims are built to current rules.
We code to the documentation, not to habit.
The outpatient E/M families every ambulatory claim runs on, billed at the level the note supports and defended when a payer asks.
| CPT code | Time band | Description |
|---|---|---|
| 99202–99205 | New patient | Office or other outpatient visit, new patient |
| 99211–99215 | Established | Office or other outpatient visit, established patient |
| 99221–99223 | Observation | Initial hospital inpatient or observation care |
| 99381–99397 | Preventive | Preventive medicine visits, by age and status |
| 99417 | Prolonged | Prolonged outpatient service, each 15 minutes |
| Modifier 25 | Modifier | Significant, separately identifiable E/M on the same day |
We know how each payer reads an outpatient claim.
Leveling scrutiny, modifier-25 policy, and telehealth rules differ by payer and change often. We track the differences so claims are built the way each one expects.
- MedicareMPFS · MAC leveling policy
- MedicaidState plans & managed care
- CommercialAetna · Cigna · UnitedHealthcare
- Blue CrossPlan-by-plan E/M policy
See what your outpatient claims are leaving behind.
A no-obligation review of your E/M mix, modifier use, and denials, with a recovery estimate on what was under-leveled.