California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 5.3 - Official Medical Fee Schedule
Section 9789.12.11 - Evaluation and Management: Coding - New Patient; Established Patient; Documentation

(1) A "new patient" is one who is new to the physician or medical group or an established patient with a new industrial injury or illness. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury or illness.

(2) An "established patient" is a patient who has been seen previously for the same industrial injury or illness by the physician or medical group.

(1) The "1995 Documentation Guidelines for Evaluation & Management Services," or

(2) The "1997 Documentation Guidelines for Evaluation and Management Services."

Both guidelines are incorporated by reference and are available on Medicare's website, or will be made available upon request to the Administrative Director.

The 1995 version is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

The 1997 version is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

(1) When the practitioner selects a visit level using time, the practitioner may report prolonged office/outpatient Evaluation and Management visit time using HCPCS add-on code G2212 (Prolonged office/outpatient E/M services). Do not report prolonged office/outpatient Evaluation and Management visit time using CPT code 99417.

(2) For services on or after March 1, 2021 and prior to February 15, 2023, HCPCS code G2212 is defined as follows:

Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services). (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes).

(3) For services on or after February 15, 2023, HCPCS code G2212 is defined as follows:

Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report G2212 on the same date of service as 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes).