Part B Insider (Multispecialty) Coding Alert

Published on Tue Sep 07, 2004 PDF

The real question is, when is an E&M service more complex?

Think identifying a problem as "new" is a piece of cake? Think again.
 
If a physician sees a patient with a serious illness for the first time, he or she may be tempted to mark the encounter as "new problem." But if other doctors in the practice have already treated the patient for that problem, you shouldn't consider it new for diagnosis and management purposes, according to one carrier.
 
The latest set of frequently asked questions from Part B carrier Palmetto GBA addresses this situation. One question cites an instance when a patient with long-term diabetes sees a new doctor in a practice where he or she has been treated before.
 
You can't raise the evaluation and management level just because the doctor hasn't treated this patient for this problem before, Palmetto says. "Even though this may be a new problem to this examiner, the medical file and related information has already been gathered" by other doctors, Palmetto notes.
 
In this situation, "you'd have to consider it an established problem," notes Karen Jeghers, manager of Compliant Billing in Carver, MA. The only exception is if a patient's diabetes or other condition suddenly runs out of control or becomes exacerbated. Because you'll be determining the level of service based on risk and medical necessity, the level of risk with controlled diabetes is minimal in any case, says Jeghers.
 
Another exception would be a multispecialty practice, says Robyn Lee with Lee-Brooks Consulting in Chicago. For example, if a diabetic has been seeing an internist, who refers her to a specialist within the same practice, you'd probably bill it as a consult instead of a new patient encounter.
 
Besides complications, other factors may bump up the E/M level, notes Lee. For example, the moment the doctor is putting the patient on new medication, the level of medical decision-making could rise. This is more true for prescription medications than for over-the-counter medications. If nobody in that practice has seen the patient for 18 months, it may justify a higher level as well, Lee says.