Wiki PE elements when charging a level 4 new patient

[medicode3]

Hello, I just wanted to see if anyone knows when charging for an Ortho new patient visit level 99204 does there need to be an 8 element body system exam? I didn't know being a specialty if you had to have the 8 full elements. HPI and ROS are perfect. Thanks

 

[jettagirlfl]

Yes, all the elements must be met to give a level 4. I do not code ortho, but I do code for a specialist.

 

[VRock]

Comprehensive exam

Hello, I just wanted to see if anyone knows when charging for an Ortho new patient visit level 99204 does there need to be an 8 element body system exam? I didn't know being a specialty if you had to have the 8 full elements. HPI and ROS are perfect. Thanks

You either have to do a single system comprehensive exam, which is not defined by 1995 guidelines, or an 8 organ system exam. Another alternative is to follow the 1997 musculoskeletal exam. However, I find most physician think the 1997 exams are not flexible enough for individualization for the patient's problems. You primarily have to prove what you are documenting/providing is a comprehensive exam.