Primary Care Coding Alert

Counseling, established patients get you an encounter faster

If you report an office visit only when your family physician documents a history, examination and medical decision-making, you could be missing reimbursement that you deserve.

You can throw the "all of the key components" rule out the window in two instances: established patient office visits and counseling-dominated encounters. To improve your reimbursement, experts reveal the essentials of E/M service coding:

Search for HEM With New Patient Visits, Consults

To bill 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) or 99241-99245 (Outpatient consultations), your FP must base the visit's level on all three key components. That means that he must take a history, perform an examination and provide medical decision-making.

Tip: Select the appropriate new patient office visit level or consultation level based on the lowest E/M component. "The history, exam and medical decision-making need to be at the same level or higher to support the level of care," says Teresa M. Thompson, CPC, CCC, a coding specialist and the owner of TM Consulting, a national medical consulting and management firm in Sequim, Wash.

Example: A school nurse requests your FP's opinion on a 15-year-old male with failing grades and suspected drug use. The physician takes a detailed history, performs an expanded problem-focused examination and uses straightforward decision-making. For the outpatient consultation, you should report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) based on the lowest component(s), the exam and decision-making, which are at the same level. Look for 2 out of 3 for 99212-99215 Supporting a higher-level service is easier with established patient office visit codes (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). You need only two of the key components to substantiate 99212-99215.

Watch out: You may accidentally downcode if you select the established patient office visit code based on three out of three components. Each of the established patient E/M codes states, "Office or other outpatient visit ... which requires two of these three key components," according to CPT.

Right way: Look for the two highest or same-level components. For instance, an allergic rhinitis patient presents for a follow-up exam and also complains of ear pain. The FP's nurse takes a detailed history. The physician reviews her notes and performs a problem-focused exam with low-complexity medical decision-making.

Based on the two highest components, the history and medical decision-making, you should report 99213 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity).

Pitfall: If you coded the above encounter using the three-out-of-three-components rule, you'd report 99212 (... [...]