Otolaryngology Coding Alert

Question:  Our physician recently saw a patient because of an abscess on her neck. He drained the abscess and asked the patient to return the following day for a follow-up visit. When she returned, the provider billed a 99213 for the follow-up. He had billed the same E/M code for the first visit on the previous day. Are we justified in reporting a Level 3 E/M code for the follow-up visit?

New Hampshire Subscriber

Answer: Just because the patient returned for a “follow-up,” 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.

However, don’t assume that the same code would automatically apply again, either. 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 physician 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.