Primary Care Coding Alert

Question: A 22-year-old female who is new to our practice presents with irregular menses. Our family physician documents a comprehensive history, comprehensive examination, and low-complexity medical decision-making. Which E/M level should I submit? Colorado Subscriber Answer: You should report a level-three new patient office visit. New patient office visit codes (99201-99205, Office or other outpatient visit for the E/M of a new patient ...) require that the physician meet the criteria that CPT designates for all three key components: history, examination, and medical decision-making. So when an FPperforms different component levels, you should select the appropriate-level new patient office visit code based on the lowest component that the FP documents. In your example, the FP performs and documents a comprehensive history and comprehensive examination. Even though these two components qualify for 99204, the FP must also document moderate-complexity medical decision-making to submit a level-four new patient code. Because he dictates low-complexity medical decision-making -- not moderate -- you should report 99203.