Revenue Cycle Insider

Question: A provider saw a new patient and spent 44 minutes at the encounter. The provider documented the patient’s health history, performed a physical exam, and recorded that they had “no concerns” but recommended that the patient make another appointment if any problems arose. A colleague wants to code this with 99204 because of the time, but I think 99203 is a better choice. Who’s right?

Washington Subscriber

Answer: Look at the code descriptors for each evaluation and management (E/M) code, as well as the provider’s documentation, to see what services support the selection of a code.

Code 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) requires at least 30 minutes of time spent and incorporates a low level of medical decision making (MDM).

Code 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) requires 45 minutes of time and a moderate level of MDM.

According to the provider’s documentation that you shared, the visit does not meet the time nor MDM complexity requirements for 99204, so 99203 would be a better, more accurate choice.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor