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This Comparative Billing Report (CBR) focuses on physicians who submit claims for Established Patient Office Visit code family (CPT codes 99211 – 99215). CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled “I AGREE”. If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled “DO NOT ACCEPT” and exit from this computer screen.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt .

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Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled “I Accept”. If you do not agree to the terms and conditions, you may not access or use software. Instead you must click below on the button labeled “I DO NOT ACCEPT” and exit from this computer screen.

Any reproduced portion of the American Hospital Association’s (AHA) Data Specifications Manual or Specifications Data (NUBC UB-04 codes) must include the following AHA disclaimer language in a prominent manner acceptable to the AHA: “The American Hospital Association (“the AHA”) has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CPT Code Level of Severity Time Spent Key Components 99211 Problem(s) are minimal. Typically 5 minutes  spent to perform or supervise. None. 99212 Problem(s) are self-limited or minor. Typically 15 minutes  spent face-to-face with the patient and/or family.   Requires 2 of these 3 key components: - A problem focused history - A problem focused examination and - Straightforward medical decision making 99213 Problem(s) are of low to moderate severity. Typically 15 minutes spent face-to-face with the patient and/or family.   Requires 2 of these 3 key components: - An expanded problem focused history - An expanded problem focused examination and - Medical decision making of low complexity 99214 Presenting problem(s) are of moderate to high severity. Typically 25 minutes spent face-to-face with the patient and/or family. Requires 2 of these 3 key components: - A detailed history - A detailed examination and - Medical decision making of moderate complexity 99215 Presenting problem(s) are of moderate to high severity.   Complex medical decision making involves at least 2 of the following: - extensive management options - extensive amount of data reviewed - high risk of complications and/or morbidity or mortality Typically 40 minutes are spent face-to-face with the patient and/or family. Requires 2 of these 3 key components:  - A comprehensive history - A comprehensive examination and - Medical decision making of high complexity

“The American Hospital Association (“the AHA”) has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.”

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “I Accept.”

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Applicable FARS\DFARS Restrictions Apply to Government Use. Please click here to see all U.S. Government Rights Provisions

Education Resources: The Provider Outreach and Education (POE) team has published an educational video session to address the issues pertinent to this CBR. Your practice is being advised to view this video.

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The AMA, ADA, and AHA only permit the use of CPT, CDT, and NUBC/UB04 data in the Technical Specifications and Resource Manuals, and Value Set Directories, for the reporting of Medicaid and CHIP Core Set measures to CMS.

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Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, https://www.ama-assn.org/go/cpt.

CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. The AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with Palmetto GBA or CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Methods The metrics reviewed in this CBR are the proportion of billing for each HCPCS code in the grouping with comparisons done to peers with the same specialty in the state and the jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. For the purpose of this CBR, 'peer group' is defined as other providers in Jurisdiction M (JM) who have the same specialty. The analysis shows the portions of your Established Patient Office Visit family of codes (CPT codes 99211-99215) claims at each level compared to your peers in JM.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled “I Accept”. If you do not agree to the terms and conditions, you may not access or use software. Instead you must click below on the button labeled “I DO NOT ACCEPT” and exit from this computer screen.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312- 893-6816.

End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

CMS DisclaimerThe scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

For your personalized Established Patient Office Visit (CPT codes 99211–99215) eCBR results Logon to eServices. Established Patient Office Visit (CPT codes 99211–99215): Coverage and Documentation Requirements

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AMA Disclaimer of Warranties and Liabilities. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, AMA Plaza, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of FAR 52.227-14 (December 2007) and/or subject to the restricted rights provisions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at ub04@aha.org.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, “you” and “your” refer to you and any organization on behalf of which you are acting.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, “you” and “your” refer to you and any organization on behalf of which you are acting.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled “I accept”, you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled “I accept”, you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement.

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)(June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of CMS. THE CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. THE CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

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You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials (web pages, PDF documents, Excel documents, Word documents, text files, Power Point presentations and/or any Flash media) internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

You, your employees and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement.