Oral Surgery Coding & Reimbursement Alert

Reader Question:

Reporting Same Level E/M for Follow-up Visits? Watch Out

Published on Tue Feb 23, 2016

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Question: Our surgeon recently saw a patient who was suffering from an abscess of the floor of the mouth. He drained the abscess and asked the patient to return the following day for a follow-up visit. When the patient returned, the provider billed a 99213 for the follow up. He had billed the same E/M code for the first visit also. Would a level 3 E/M be justified to bill even though the visit was “only” for a follow up?New York Subscriber

Answer: Just because the patient returned for a “follow-up” visit, you should not assume that you cannot bill an E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) for the visit.

On the other hand, you should base your decision about choosing the level of E/M code on the service that your clinician has provided. Make your decision based on the documented elements of History, Physical Exam, and Medical Decision Making (MDM), unless counseling/coordination of care dominates the encounter (in which case you can select your code based on time). If your physician’s documentation fulfills the code’s minimum criteria, then you can be justified in your selection of the particular E/M code for the visit.

Coding tip: Don’t automatically select the same E/M code each time your clinician recalls the patient for a follow-up visit. If you select the same level E/M code for the first and the follow up visits without properly checking the documentation, you might end up raising some red flags and may invite unnecessary trouble. On the other hand, if you fail to identify the level of E/M performed by your clinician in the follow-up visit, you might end up losing out on deserved reimbursement.