doctor office visit level 2

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

What drives the level of office visit codes?

Many physicians and coders think longer documentation means charging higher level visits. Fortunately, that is not always the case. You can document less as long as you are documenting the correct and necessary information.

Medical decision making drives the level of office visit

The medical decision-making portion of evaluation and management guidelines is what ultimately determines the level billed. Higher complexity in decision making justifies higher levels.

Evaluation and Management visits have three main components:

• Physical exam
• Medical decision making.

For established patients, guidelines state that only two of these three need to be met for a given level. The Center for Medicare and Medicaid Services advises to let medical decision making drive the visit.

What does “Medical decision making should drive the visit” really mean?

This is such a grey area in the guidelines that it is causing practices to over-bill or undercharge, which will ultimately cause them to fail an audit.

CMS stated, “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.” ( Medicare Claims Processing Manual 30.6.1)

Many practices are so confused about what this means, that they just pick the middle level and call it a day. Those practices need clarification and education on how to get to the correct level for the service performed. MEREM can help!

Below are some examples to remember when choosing the level of an office visit to the bill.

• If the provider is seeing an established patient who is coming in for a recheck,  ask yourself is the patient’s diagnosis improving or worsening?

– If the problem is improving, the level of service will likely be a level 2 (99212).

⁃ If the problem is worsening, the level of service is likely a level 3 (99213).

• For established patients coming in with a new problem , these level of service is likely a level 3 (99213) or level 4 (99214). The final level for this patient will depend on the diagnosis and treatment performed during the service.
• Code 99215 is used to report High MDM. 99215 is reserved for those patients who require extensive workup regarding Chronic Illnesses with severe exasperations or acute illness or injuries that threaten loss of life or bodily function. Management options for these patients may include IV drug therapy, Emergency Surgery or a DNR status because of poor prognosis.

Let MEREM Health help you conquer the challenges of coding your office visits. Call us to get a free quote at 205-329-7519.

© 2024 MEREM Health. All Rights Reserved.

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Office ergonomics: Your how-to guide

Understanding office ergonomics and arranging your workspace accordingly can help you feel good throughout the workday.

If your work involves sitting at a desk, discomfort doesn't have to be part of the job. You may be able to avoid some of the health problems associated with seated work, such as neck and back pain and sore wrists and shoulders, by using proper office ergonomics. Chair height, equipment spacing and desk posture all make a difference.

Use this guide to ease stress on your body, protect your joints and help you stay comfortable as you work.

Choose a chair that supports your spine. Adjust the height of the chair so that your feet rest flat on the floor. Or use a footrest so your thighs are parallel to the floor. If the chair has armrests, position them so your arms sit gently on the armrests with your elbows close to your body and your shoulders relaxed.

Under the desk, make sure there's enough room for your legs and feet. Don't store items under your desk, as that can shrink the amount of available space and make it hard to sit correctly. If the desk is too low and the desk height can't be changed, put sturdy boards or blocks under the desk legs to raise it. If the desk is too high and can't be changed, raise your chair. Use a footrest to support your feet if necessary. If you don't have a footrest, try using a small stool or a stack of sturdy books. If your desk has a hard edge that's not rounded, pad the edge or use a wrist rest. This protects your wrists from a problem called contact stress that can happen as a result of extended contact with a hard edge.

Keyboard and mouse

Put your computer keyboard in front of you so your wrists and forearms are in line and your shoulders are relaxed. If you use a mouse or another type of pointer connected to a computer, place it within easy reach, on the same surface as your keyboard. While you are typing, using a computer touchpad, or using a mouse or pointer, keep your wrists straight, your upper arms close to your body, and your hands at or slightly below the level of your elbows. If possible, set the sensitivity of the mouse or pointer so you can use a light touch on it.

Place the computer monitor straight in front of you, directly behind your keyboard, about an arm's length away from your face. The monitor should be no closer to you than 20 inches (about 50 centimeters) and no further away than 40 inches (about 100 centimeters). The top of the screen should be at or slightly below eye level. If you wear bifocals, lower the monitor an additional 1 to 2 inches (about 2 to 5 centimeters) for more comfortable viewing.

Using a laptop computer may lead to discomfort because of the low screen height and cramped keyboard and touchpad. If you use a laptop at your desk, consider getting an external keyboard and mouse, along with a laptop stand, to more closely mimic a desktop computer setup.

Frequently used objects

Keep objects you use often — such as the phone, stapler or printed materials — close to your body to minimize reaching. Stand up to get anything that you can't comfortably reach while sitting.

If you spend a lot of time on the phone, or if you often type or write while you're using the phone, put the phone on speaker or use a headset. Don't cradle the phone between your head and neck.

Remember, no matter how well your workspace is set up for proper ergonomics, sitting in the same position for hours at a time isn't good for your body. Get up and walk around as often as you can throughout the workday. If possible, do some work standing up. While you're seated, stretch your hands, fingers and arms from time to time. Shifting your position, standing up and moving will ease strain on your body and help you stay healthier.

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• Computer workstations: Positions. Occupational Safety and Health Administration. https://www.osha.gov/etools/computer-workstations/positions. Accessed Jan. 17, 2023.
• Computer workstations: Workstation components — Chairs. Occupational Safety and Health Administration. https://www.osha.gov/etools/computer-workstations/components/chairs. Accessed Jan. 17, 2023.
• Computer workstations: Workstation components — Desks. Occupational Safety and Health Administration. https://www.osha.gov/etools/computer-workstations/components/desks. Accessed Jan. 17, 2023.
• Computer workstations: Workstation components — Keyboards. Occupational Safety and Health Administration. https://www.osha.gov/etools/computer-workstations/components/keyboards. Accessed Jan. 17, 2023.
• Computer workstations: Workstation components — Pointer/mouse. Occupational Safety and Health Administration. https://www.osha.gov/etools/computer-workstations/components/pointer-mouse. Accessed Jan. 17, 2023.
• Computer workstations: Workstation components — Telephones. Occupational Safety and Health Administration. https://www.osha.gov/etools/computer-workstations/components/telephones. Accessed Jan. 17, 2023.
• Computer workstations: Workstation components — Monitors. Occupational Safety and Health Administration. https://www.osha.gov/etools/computer-workstations/components/monitors. Accessed Jan. 17, 2023.
• Gecht-Silver MR, et al. Overview of joint protection. https://www.uptodate.com/contents/search. Accessed Jan. 17, 2023.
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How to find the right balance between telemedicine and in-person care

FILE - A patient sits in the living room of her apartment in the Brooklyn borough of New York during a telemedicine video conference with a physician on Jan. 14, 2019. Patients can now see an array of doctors without leaving their recliner thanks to telemedicine. But that doesn’t mean trips to the office should end. Finding the right balance between virtual and in-person visits can be a key to getting good care. (AP Photo/Mark Lennihan, File)

FILE - A doctor examines a patient at a clinic in Stanford, Calif., on April 9, 2019. Patients can now see an array of doctors without leaving their recliner thanks to telemedicine. But that doesn’t mean trips to the office should end. Finding the right balance between virtual and in-person visits can be a key to getting good care. (AP Photo/Jeff Chiu, file)

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Patients can now see an array of doctors without leaving their recliner thanks to telemedicine. But that doesn’t mean trips to the office should end.

Finding the right balance between virtual and in-person visits can be a key to getting good care.

Here’s what you need to know about which form of care may be right for you and when.

WHAT IS TELEMEDICINE?

This generally refers to diagnosing and treating patients remotely. It’s often done over a secure video connection provided by the doctor’s office. You can use your smartphone, tablet or computer.

But telemedicine also can involve telephone calls or trading secure messages with someone from your doctor’s office to discuss test results or follow-up steps after an appointment.

It can be used to diagnose new health problems and monitor existing, long-term issues like diabetes.

WHAT’S THE BUZZ?

These virtual visits can save time and give patients more doctor choices. That’s especially important for those who live where in-person care options are slim or for patients who can’t take time off work to get to the doctor or lack transportation.

Telemedicine use exploded after COVID-19 hit in 2020. It has cooled since, but it remains more popular than it was before the pandemic, particularly in specialties like dermatology or mental health care.

Amazon now offers a telemedicine option in every state. And many companies sell subscription-based plans centered on virtual care. For those, patients pay a regular fee for doctor visits and mail-order prescriptions to treat high blood pressure, anxiety or hair loss, among other issues.

WHAT ARE THE KEYS TO A VALUABLE VISIT?

Test your phone or tablet before the visit starts. You will want to make sure both audio and video work properly. You may need time to adjust your device settings.

Make sure you’re in a room or location that offers privacy, especially for therapy sessions. That’s usually not a work cubicle, library or restaurant with public Wi-Fi.

Don’t drive, walk or eat while talking to the doctor. Aside from being unsafe, those habits also can be distracting for both the patient and physician, noted Dr. Jay Lee, a family physician who does both in-person and virtual visits.

WHAT ARE THE LIMITS?

Telemedicine needs a secure, fast internet connection, and some patients or doctors may lack the technology to do a virtual visit.

Sometimes physical exams are necessary.

Someone seeking help for a urinary tract infection — which can be treated by telemedicine — might actually have gallbladder problems. That could require an ultrasound during an in-person visit, noted Lee, a board member with the American Academy of Family Physicians.

There also may be limits to receiving telemedicine from doctors outside your state. Pandemic emergency declarations that made this easier have ended .

That can make follow-up care challenging if a patient travels to see a specialist.

“There aren’t that many pediatric specialists in all of the different conditions that can affect kids,” said Krista Drobac, founder of the Alliance for Connected Care, which advocates for telemedicine use.

WHAT’S THE RIGHT BALANCE?

That can depend on the patient’s comfort with telemedicine and the treatment they need.

In some cases, there is no balance if a patient lacks an in-person option or that visit is tough to schedule.

If possible, Lee recommends an initial visit in person and then telemedicine follow-ups. He says that first visit is important for any doctor or specialist you expect to see again.

Both the physician and patient need to determine whether they “have a vibe, that they can get along and that they can work together,” he said.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

When to go to the emergency room or doctor’s office

May 19, 2021

Consider these three factors when deciding whether to go to the emergency room or your primary care doctor for an illness or injury.

Symptom severity

Emergency room: Go to the emergency room for any condition that threatens life or limb. Symptoms that should prompt an ER visit include chest pain, obvious trauma, bleeding that won’t stop, difficulty breathing, sudden weakness or confusion, severe pain and mental health crises.

Doctor’s office: Visit your primary care doctor for colds, flu, muscle strains, sprains, chronic disease management, headaches, trouble sleeping and nonurgent mental health issues. For COVID-19 symptoms, call first.

Emergency room: ERs treat their sickest patients first, so you may have to wait if other people’s needs are more urgent.

Doctor’s office: Primary care visits are scheduled on a first-come, first-served basis. Having an appointment means you won’t have a long wait once you get to the office.

Emergency room: ERs are more costly but are equipped to deal with many ailments.

Doctor’s office: This is often your least expensive option, usually costing only a copay.

Healthcare from home

Get expert remote care from Adventist Health Clear Lake providers.

Virtual doctor visits: Providers can treat minor illnesses and injuries virtually. Access telehealth care from a smartphone, tablet or computer with a camera and microphone. Ask to be seen virtually when scheduling your appointment.

Hospital@Home : Your home can be transformed into a virtual hospital. Adventist Health’s medical team provides 24/7 monitoring to assess your condition and dispatches clinicians, medication and services to your home as needed.

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Doctor of Education Leadership

Additional Information

• Download the Doctoral Viewbook
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America needs transformative leaders in preK–12 education whose passion for education quality and equity is matched by a knowledge of learning and development, the organizational management skills to translate visionary ideas into practical success, and a firm grasp of the role of context and politics in shaping leadership. Graduates of the three-year, multidisciplinary Doctor of Education Leadership (Ed.L.D.) Program at the Harvard Graduate School of Education will be prepared to become those leaders.

The Ed.L.D Program — taught by faculty from the Harvard Graduate School of Education, the Harvard Business School, and the Harvard Kennedy School — will train you for system-level leadership positions in school systems, state and federal departments of education, and national nonprofit organizations. Ed.L.D. is a full-time, three-year program built on a cohort learning model. Cohorts consist of up to 25 students from diverse professional backgrounds (including district/charter management leaders, nonprofit directors, principals, teachers, and policy researchers) who progress through the program together.

All Ed.L.D. students receive a full tuition funding package plus stipends, work opportunities, and a paid third-year residency at a partner organization.

The Ed.L.D. Program prepares graduates to do work for the public good in the American public education sector, whether that be at the system or state level. Specifically, the program is designed to accelerate the progress graduates make toward achieving meaningful impact in influential roles and/or crossing boundaries in the following spaces in the public education sector:

• PreK–12 district or CMO leadership roles : superintendent of schools, chief academic officer, and/or deputy superintendent
• Foundation/philanthropy roles:  director, president and CEO, senior fellow
• Education nonprofit roles : president or executive director of backbone or collective impact organizations which support preK–12 schools. Ed.L.D. graduates will lead education nonprofits that explicitly focus on improving outcomes and opportunities for children, families, and communities.
• State or federal education leadership roles : commissioner or deputy commissioner roles. Could also include public education advocacy or education policy advisers to senior government officials.
• Social Entrepreneurship and Innovation roles:  Founder, CEO, president

Curriculum Information

The Ed.L.D. curriculum is a balance of multidisciplinary coursework and practice-based learning. Core courses and electives are taught by recognized leaders from across Harvard’s graduate programs in fields like data-based education reform, organizational change and innovation, and effective leadership strategies for urban schools. You will develop and test your leadership skills through team projects and an immersive third-year residency.

All students in the cohort take the same classes in four foundational content areas: learning and teaching, leadership and organizational change, politics and policy, adult development, and leadership inside and out (including one-on-one executive coaching). Courses taken during the first-year focus on practice-based learning and serve as the framework of your first-year experience.

Sample HGSE Courses

• Leading Change
• How People Learn
• Ed.L.D. Proseminar
• Leadership, Entrepreneurship, and Learning
• Race, Equity, and Leadership
• Practicing Leadership Inside and Out
• Sector Change
• The Workplace Lab for System-Level Leaders

View  all courses  in the Academic Catalog.

Each cohort member works with program advisers to choose an individualized sequence of electives from any of the Harvard graduate schools. You will work closely with the program faculty and staff during your second year to determine the best match with a partner organization for your third-year residency. Matches are driven by mutual interest between the resident and the partner organization, and each student's career and learning goals and geographic preferences.

• Second Year Practicing Leadership Inside and Out
• Driving Change 
• Education Sector Nonprofits
• Negotiation Workshop
• Coaching with Equity in Mind
• Ethnic Studies and Education
• Deeper Learning for All:  Designing a 21st Century School System
• Institutional Change in School Organizations, Systems, and Sectors

You will take part in a 10-month paid residency at one of our partner organizations. There, you will work on a strategic project which synthesizes your experience and learning into a written Capstone project. You will stay connected to your Ed.L.D. cohort and HGSE through technology and by returning to Harvard periodically for intensive workshops.

Paid Residency 

Our partner organizations include school systems and departments of education, as well as some of the nation's most influential and dynamic nonprofit, mission-based for-profit, and philanthropic organizations.

You will be intentionally pushed out of your comfort zones and asked to work systemically and make a significant contribution to the partner organization. In addition, the residency will provide you with the professional mentoring, practical experiences, and network of connections they need to position themselves as future leaders in the education sector. 

Strategic Project 

You will define (with supervisors from your partner organization) a strategic project on which to focus. You will have the opportunity to lead one or two major efforts on behalf of the organization, such as the creation or implementation of current initiatives. The project allows you to practice and improve leadership skills, add important value to the mission and strategy of the partner organization, work systemically, and hold high-level accountability.

During the residency period, you will produce a written Capstone. The Capstone is a descriptive, analytic, and reflective account of your third-year leadership contributions to a strategic project within an Ed.L.D. partner organization. It is a demonstration of your ability to engage others, develop strategy to successfully address and diagnose challenges, work toward a vision and goals, and learn from the results.

Sample Topics

• Accountability, Coherence, and Improvement: Leadership Reflection and Growth in the Los Angeles Unified School District
• Leadership Development for Entrepreneurial Education Leaders Working to Build Public & Private Sector Support
• Disrupting Teacher Preparation: Lessons in Collaboration and Innovation Across the Learning to Teach Community of Practice
• Pursuing Educational Equality for English Language Learners

Sample Summaries 

• Breaking Down Silos in a School District: Findings from an Ed.L.D. Project in Montgomery County
• Expanding Students' Access to Meaningful STEM Learning Opportunities Through Strategic Community Partnerships
• Developing a New Teacher Leadership and Compensation System in Iowa: A Consensus-Based Process
• Finding Great Teachers for Blended-Learning Schools

GSE Theses and Dissertations from Digital Access to Scholarship at Harvard (DASH)

Program Faculty

Ed.L.D. students learn with renowned faculty from the Harvard Graduate School of Education, Harvard Business School, and Harvard Kennedy School. Faculty from the three schools share their individual expertise in the Ed.L.D. Program and work collaboratively to provide a challenging and coherent experience for students. Faculty who teach in the Ed.L.D. core curriculum and advise Ed.L.D. students include:

Faculty Director

Frank D. Barnes

Frank Barnes is faculty director of the Doctor of Education Leadership Program. He has over 30 years experience as an educator, researcher, and organizer. As a chief accountability officer, he led turnaround efforts for large public school districts, including Boston Public Schools and Charlotte-Mecklenburg Schools.

Kathryn Parker Boudett

Ebony N. Bridwell-Mitchell

Jennifer Perry Cheatham

Elizabeth City

Candice Crawford-Zakian

Marshall Ganz

Adria D. Goodson

Deborah helsing.

Monica C. Higgins

Deborah Jewell-Sherman

Lisa Laskow Lahey

Mary Grassa O'Neill

Irvin Leon Scott

Catherine Snow

Michael L. Tushman

Martin west.

Introduce Yourself

Tell us about yourself so that we can tailor our communication to best fit your interests and provide you with relevant information about our programs, events, and other opportunities to connect with us.

Program Highlights

Explore examples of the Doctor of Education Leadership experience and the impact its community is making on the field:

Do We Need Happiness Teachers?

After a trip to meet with the Dalai Lama, an Ed.L.D. student says we do

Combatting Chronic Absenteeism with Family Engagement 

As post-COVID absenteeism rates continue unabated, a look at how strong family-school engagement can help

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• Both parents or guardians must approve that we can issue a passport to a child, and go with the child to apply in person.
• If one or both parents or guardians cannot apply with their child, you will need to show us more documents.
• You cannot renew your child's passport using Form DS-82.
• Passports for children under age 16 are only valid for 5 years. 

Steps to Apply

1. fill out form ds-11 and print it.

Use our Form Filler tool  to fill out your child's form on a desktop or laptop computer and then print it. If you are experiencing technical issues with the Form Filler, download a PDF . 

Tips to complete your child's form :

• Do not sign your child's form until asked to do so by a passport acceptance agent or employee. 
• You can apply for a passport book , a passport card , or both documents.
• You may ask for a larger passport book with more visa pages, at no extra cost, by checking the 'large book' box at the top of the DS-11.

2. Get Evidence of U.S. Citizenship (and a photocopy)

Your evidence must be an original or replacement copy. The document must have the official seal or stamp of the office which issued it. You must submit one of the following documents for your child:

• Issued by the city, county, or state of birth
• Lists applicant's full name, date of birth, and place of birth
• Lists the parent(s)' full names
• Has the date filed with registrar's office (must be within one year of birth)
• Has the registrar's signature
• Has the seal or stamp of the city, county, or state which issued it
• Consular Report of Birth Abroad or Certification of Birth
• Certificate of Citizenship
• Please note you must also provide a document, such as a birth certificate, that lists the parent(s) or legal guardian(s) of the child. Full validity means the document is or was valid for 10 years for adults and 5 years for children under 16. 

If you cannot submit one of these documents, go to our  Citizenship Evidence page  for more information.

Paper only : You cannot submit digital evidence of U.S. citizenship such as a mobile or electronic birth certificate. You must submit physical evidence of U.S. citizenship and a photocopy of the document. 

Returning your child's document : We will return your child's document in a separate mailing up to 8 weeks after you receive the new passport.

Tips for making a photocopy :

• Black and white (no color)
• Use 8.5 inch by 11 inch paper
• Use a single side of the paper

If you do not submit a photocopy, you must submit a second copy of your citizenship evidence. We will keep this copy for our records.

3. Show Your Relationship to Your Child

You must submit a document that lists the parent(s) or legal guardian(s) of the child. Examples include:

• U.S. birth certificate (also evidence of U.S. citizenship)
• Foreign birth certificate
• Adoption decree
• Divorce or custody decree
• A court order

Some documents, like a U.S. birth certificate, show  both  U.S. citizenship and parental relationship. These documents must be originals or certified copies (not photocopies).

You and your child may have different last names, as long as the document showing your relationship to your child lists your full name.

If your name is different than the one on the document showing your relationship to your child, submit proof of your legal name change.

4. Get a Photo ID (and a photocopy)

Both parents or guardians must bring a physical, photo ID and a photocopy of it. If your photo ID is from a different state than the state in which you are applying, bring a second photo ID. 

You must show at least  one  of these photo IDs:

• Valid or expired, undamaged U.S. passport book or passport card 
• In-state, fully valid driver's license or enhanced driver's license with photo
• Certificate of Naturalization 
• Certificate of Citizenship 
• Government employee ID (city, county, state, or federal)
• U.S. military or military dependent ID
• Current (valid) foreign passport
• Matricula Consular (Mexican Consular ID) used by a parent of a U.S. citizen child applicant
• U.S. Permanent Resident Card (Green Card) used by a parent of a U.S. citizen child applicant
• Trusted Traveler IDs (including valid Global Entry, FAST, SENTRI, and NEXUS cards)
• Enhanced Tribal Cards and Native American tribal photo IDs
• In-state, fully-valid learner's permit with photo
• In-state, fully-valid non-driver ID with photo
• Temporary driver's license with photo

If you do not have one of these photo IDs, go to our  Identification page  for more information.

5. Show More Documents (if both parents or guardians cannot apply)

• Both parents or guardians must approve that we can issue a passport to a child, and go with the child to apply in person.
• If one or both parents or guardians cannot apply in person with their child, you will need to show more documents.

Important : Submit  Form DS-3053  and other notarized statements within three months of signing them.

6. Provide a Photo

You must provide one photo with your child's application. Go to our  Passport Photo page  for photo requirements and to see examples of photos. 

• Do not attach or staple your child's photo to the form. The acceptance agent or passport employee will review the photo and staple it to your form.
• Some  passport acceptance facilities
• A company which offers photo services
• Home. Ask your friend or family member to take your child's photo. Print it on glossy or matte photo quality paper. 

7. Calculate Fees

When applying using Form DS-11, you will pay two separate fees - an application fee and an execution (acceptance) fee. You will pay the application fee to the U.S. Department of State, and the execution (acceptance) fee to the facility which takes your application. 

• Add $60 to your application fee if you want  expedited service .
• Add $19.53 to your application fee if you want us to ship your completed passport in 1-2 days after we issue it.  

Child Applicants :

For more information on how to pay and a full list of fees, go to our  Passport Fees  page.

*How to fill out your check and pay the application fee to the U.S. Department of State. Please note you must pay a separate execution (acceptance) fee. 

Families may write one check or money order to the U.S. Department of State if they are applying at the same time. The check or money order must include the name and date of birth of each applicant.

8. Find Location to Apply

In the United States:

• Traveling in more than 3 weeks?  Go to a  passport acceptance facility  such as a post office, library, or local government office. Check with the facility to see if you need to make an appointment. 
• Traveling in less than 3 weeks?   Make an appointment  to apply at a passport agency or center.

In another country:

• Contact your  U.S. embassy or consulate .

9. Track Your Application Status

You can  subscribe to email updates  about your application status, and  learn more about each status update .

It may take 2 weeks from the day you apply until your child's application status is “In Process.” 

Frequently Asked Questions

How will you send my child's passport and supporting documents.

You will get multiple mailings. The number of mailings depends on what document(s) you asked for.

Passport Book : You may get your new passport and citizenship documents in two mailings. You may wait 8 weeks after getting your passport before you get a second mailing with your citizenship documents. We will return the passport book using a trackable delivery service.

Passport Card : You may get your new passport card and your citizenship documents in two mailings. You may wait 8 weeks after getting your passport before you get a second mailing with your citizenship documents. We only send the passport card via First Class Mail. We do not send cards using 1-2 day delivery services.

Both a Passport Book and Card : You may get three separate mailings:

• New passport book
• New passport card
• Citizenship documents

Contacting Us : If you have been waiting more than 8 weeks for your documents, call us at  1-877-487-2778  to report that you have not received your documents. 

If you want us to reimburse you for a lost supporting document, you must contact us within 90 days of the date which we mailed your passport. You will also need to provide a receipt to show the cost of replacing the document. 

Can I pay for faster delivery and return shipping?

Yes. You may choose one or both of the following shipment options:

• Delivering application to us : Pay for Priority Mail Express for faster shipping. The price for this service varies depending on the area of the country.
• Returning the passport to you : Pay $19.53 for 1-2 day delivery. This means you will receive your passport   1-2 days after we send it. Include this fee with your check or money order payable to the U.S. Department of State. Do not submit a return envelope to us with postage pre-paid. 

You may receive your passport and supporting documents in separate mailings. If you are renewing a passport card, we will send it to you via First Class Mail. We do not use 1-2 day delivery services if you only applied for a passport card.

What countries require Form DS-3053 "Statement of Consent" to be notarized at an embassy or consulate?

In certain countries, a DS-3053 must be notarized at a  U.S. embassy or consulate  and cannot be notarized by a local notary public. Currently, these countries include:

Special Passport Fairs

Find a Special Passport Fair  near you!

We're holding special passport fairs all across the United States to help you get your passport more easily. New events are added to our site every week.

Most events are for first-time applicants and children, (who use Form DS-11). If you can use Form DS-82, you can renew by mail at your convenience!

Processing Times

Routine:  6-8 weeks*

Expedited: 2-3 weeks and an extra $60*

*Consider the total time it will take to get a passport when you are booking travel.  Processing times only include the time your application is at a passport agency or center.

• It may take up to 2 weeks for applications to arrive at a passport agency or center. It may take up to 2 weeks for you to receive a completed passport after we print it. 
• Processing times + mailing times = total time to get a passport

Urgent Travel:  See our Get my Passport Fast page. 

How to Apply for your Child's Passport

Watch this video to learn how to apply in person for your child's U.S. passport!

External Link

You are about to leave travel.state.gov for an external website that is not maintained by the U.S. Department of State.

Links to external websites are provided as a convenience and should not be construed as an endorsement by the U.S. Department of State of the views or products contained therein. If you wish to remain on travel.state.gov, click the "cancel" message.

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If you're forgetting to bill 99211 for nursing visits, or using 99201 when you should be using 99202, this quick coding lesson may improve your practice's bottom line .

JAMES M. GIOVINO, MD

Fam Pract Manag. 2000;7(7):39-42

Level-one” office visits may be the simplest of patient encounters, but when it comes to coding and documentation, they are widely misunderstood. More often than not, we tend to forget to bill 99211 for nursing visits and we undercode physician visits. One of the key problems, of course, is that the rules for coding and documentation are clear as mud, while the threat of audit is clear as day. The revised revised documentation guidelines, which are at least a year away from being implemented, may help the situation. But until then, family physicians can do better by reacquainting themselves with the most effective use of level-one evaluation and management (E/M) office visit codes.

According to the CPT manual, a 99211 is an office or other outpatient visit “that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.” Unlike the rest of the office visit codes, 99211 does not have any documentation requirements for the history, physical exam or complexity of medical decision making. The nature of the presenting problem need be only “minimal,” such as monthly B-12 injections, suture removal, dressing changes, allergy injections with observation by a nurse, and peak flow meter instruction. (For more examples, see Appendix D of the CPT manual.)

KEY POINTS:

Physicians generally should not use a 99211 code for their own services, but it may be appropriate for office services performed by a nurse.

To support the 99211 code for a nursing visit, a practice must have sufficient documentation.

If physicians use code 99201 regularly, they are likely undervaluing or under-documenting their services.

None of these visits requires the presence of a physician in the exam room (although the physician should be on the premises). In fact, as a rule of thumb, a physician should not code a 99211. What these visits do require is supporting documentation, so if you plan to charge for nurses' visits, you need to train your nurses to provide very basic medical documentation. I have found the most successful method for achieving adequate and consistent documentation from nurses is to make simple, check-box-driven forms, which guide nurses' decision making, protect you from litigation and give you the clinical data you would want yourself. (For examples of flow sheets that can assist nurses in documentation, see " Documenation help .")

Documentation help

Nurse charting for 99211 visits can be minimized and made more efficient by moving it almost entirely to flow sheets, such as the two available for download below. Longer notes, such as involved phone messages, can be documented in the progress note section of the chart to avoid filling up the flow sheet with narrative information. Nursing data need not be repeated in the progress note.

In the flow sheet for depo-progesterone injections (

), the idea is, first, to collect the data needed to protect the patient from iatrogenic injury; second, to drive effective billing; and third, to minimize the effort needed for adequate documentation.

The vital signs flow sheet (

) not only improves nurses' documentation but improves physician efficiency as well by allowing for rapid review of vital signs, past office visits, routine health care and medications. To inform the physician of a chief complaint, the nurse can simply attach a sticky note to the front of the chart. Scan the sample vital signs flow sheet and see if you can get a feel for this patient without reading the progress notes.

Note that, in our practice, we highlight no-show appointments and narcotic/benzodiazepine prescriptions in green and yellow, respectively. We have found that these features alone make the form worthwhile.

If you are not sure it is worth the effort to bill for a 99211, consider that a nursing visit for a depo-progesterone shot can generate a charge of approximately $150 (nursing visit 99211=$30, Depo-Provera 150 mg J1055=$90, urine pregnancy test 81025=$38), which even after insurer discounts is a significant amount. In my office, before we standardized nursing documentation and billing, we failed to capture approximately $4,000 per year for various portions of the nursing visit for depo-progesterone shots alone. The cost to standardize nursing documentation is minimal: a few copies of a form per year. The nurses spend no more time charting and are less confused about what they should be doing.

One word of caution about 99211: You can't bill for the administration of an injectable medication (90782) or for the administration of an immunization (90471, 90472) and a nursing visit at the same time. You can either bill for the 99211 plus the medications or bill for the injection plus the medications. When the nurse must make an evaluation of the patient (e.g., when giving a depo-progesterone shot, the nurse must consider, “might the patient be pregnant?”), then our practice uses the 99211. If the nurse must only give an injection, we use the injection codes.

In general, of the “new patient” codes, 99201 should be used only slightly less frequently than 99205. The goal is not to game the system and upcode, but if you find yourself using 99201 regularly, consider auditing your own billing and documentation practices. You will most likely find that you are either undervaluing your services or underdocumenting.

The 99201 code has more specific requirements than 99211 when it comes to elements of the history, physical and medical decision making. (See the table below, for the minimum required elements .) In addition, 99201 is not to be used for nursing visits, as the physician needs to see the patient and establish a care plan before nurses' visits can be billed.

Examples of typical 99201-type office visits from the CPT manual include an out-of-town patient needing refills on an NSAID, a topical preparation or an antihistamine for allergies. For documentation, remember to record a chief complaint, one element from the HPI and one physical exam bullet, and specify a diagnosis and plan.

99201 quick reference

Unlike code 99211, which has no specific documentation requirements, code 99201 for the evaluation and management of a new patient requires a problem-focused history, a problem-focused examination and straightforward decision making, as outlined in the table at right.

Bottom line

When it comes to level-one office visits, three general rules should keep you on track:

Don't forget to bill for the nurse's time and expertise by using the 99211 code.

Use check-box forms to drive adequate documentation, to achieve consistency between nurses and to capture all appropriate fees.

Consider the use of a 99211 or 99201 for a physician visit as a red flag indicating potential undercoding.

If you are tempted to downcode for your poorer patients, remember that you will be committing fraud by billing one group of patients differently from another. Medicare gets very upset about this. The best way to help your patients who are less able to pay is to use the correct billing codes and documentation but use financial hardship forms to adjust their bills or set up reasonable payment schedules.

Proper coding and documentation is crucial to the success of any medical practice. If you spend a little time making sure you and your staff understand level-one visits, you may find that it enhances your practice's bottom line and protects you from legal trouble.

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