If a patient comes for an office visit (ie, 99202 - 99215 ) and the clinician completes either an Asthma Control Test (ACT) or a Rhinitis Control Assessment Test (RCAT) form during the visit, would it be appropriate to report code 96160 for the completed and reviewed test in addition to the E/M code? Or are these assessment forms not reportable due to the E/M code reported for the office visit? ...
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Article Overview
This short coding guidance article addresses whether standardized patient assessment forms completed during an office visit may be reported separately from the office E/M service. It is aimed at medical coders, billers, and clinicians who need to understand the general distinction between assessment administration and the visit-level service, and it discusses the use of a standardized instrument in the context of routine outpatient encounters.
Why This Topic Matters
It helps readers determine whether a separately reportable assessment service may be considered alongside an office visit and clarifies the general scope of work captured by the E/M service versus the assessment process.
What You Will Learn
- How standardized patient assessment forms are treated in the context of an office visit
- How assessment administration relates to the broader E/M service
- What types of encounter-level documentation the article discusses at a high level
- How the article frames the distinction between administering a tool and the physician’s visit work
Who Should Read This
- Medical coders
- Medical billers
- Physicians
- Clinicians
- Practice managers
Codes Discussed
Code Ranges Discussed
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