1. J

    2023 E/M guidelines

    The guidelines that will go into effect 1/1/2023 are available. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf Enjoy! :geek:
  2. J

    Question Do in office procedures count toward MDM column 3?

    If a physician decides to give and bill for an injection during an office visit does this count toward the MDM (column 3)? Patient presented with plantar fasciitis which is progressing in pain over the past several months. The provider then performed below injection: "At this time, the foot...
  3. K


    Hello, Is bacteremia considered high risk on the table of risk chart? The provider is treating the bacteremia with IV antibiotics.
  4. A

    Depression and Anxiety Screenings (96127)

    Do you charge for screenings for anxiety and depression (96127X2) if they are done during every psych visit (99202-99205 or 99212-99215)? I feel that these would be part of the E/M since they are done on every patient in the psych clinic, but I was wondering what views others had.
  5. B

    Telehealth E/M Codes + Modifier Requirements

    I am looking for coding scenarios/examples on which E/M codes to assign for telehealth visits at a provider based facility. (We are a CAH with a family medicine clinic, majority of telehealth is the family health clinic) Based on what I'm reading in my CPT book, we should be using the 9944x...
  6. KStaten

    Recommendation for Dental prophylaxis Following Joint Replacement- MDM

    Hello, Everyone. :) Dental prophylaxis is often recommended for patients following joint replacement, whereas any vulnerable areas for infection in the body can pose a potential risk. If, however, the doctor documents-- in a routine, yearly exam-- that there are no problems with the...
  7. C

    E/M Consultation - CPC exam prep question - help

    I am sitting for my CPC exam on Saturday. There is a question in the Study Guide that has me stumped (and my two CPC colleagues too). A 55-year-old patient is seen in an office visit by an otolaryngologist. Dr. Nettles, at the request of her primary care provider for sudden hearing loss. The...
  8. KStaten

    E/M Level for Pain Following Hip Replacement (Outside Global Period)

    Hello, everyone. :) Does anyone think this would justify a 99213 with the new guidelines or would it only meet the requirements for a 99212? (Input is greatly appreciated!) -------------------------------------------------------------------------------------------------------------------------...
  9. K

    Question E/M and Procedure same day, New patient

    If a patient is referred to us for Epistaxis R04.0 and we have never seen them before, we do the E&M and it is decided that the patient needs a scope. Can we bill a new patient visit and a scope on the same day 99204 with a 25 modifier 31231 Nasal Endoscopy?
  10. J

    Modifier 27 help

    Hi all! I'm looking for resource material regarding the use of Mod-27. I code for an ED with affiliated Primary and Specialty Care offices and Walk-In's. At some point, someone in my organization advised we could not use Mod-27 with ED E/M's when a patient has an additional outpatient visit that...
  11. KStaten

    Question Are Medicare's Guidelines for E/M CPT Codes the same as AMA's?

    Hello, Everyone. :) I would greatly appreciate it if you could please share documentation that shows how "closely" Medicare bases its guidelines in comparison to AMA's rules/ guidelines regarding levels for E/M-- specifically, the MDM table. 😐 It has recently been suggested to me that the rules...
  12. M

    Observation Codes and POS 21

    Hello, can observation codes be billed under POS 21?
  13. morganscott

    Question AMA in the ED

    When a patient leaves AMA (against medical advice), can an E/M level be applied? Can you bill for ED charts when a patient leaves AMA? (Critical Access Hospital)
  14. KStaten

    MDM for Total Hip / Knee Replacement

    Hello Everyone. :) I have gone down a rabbit hole on coding joint replacement surgeries and would 💙GREATLY APPRECIATE💙 your input for confirmation, given the 2021 E/M guidelines. I apologize in advance for the redundancy of this question. A ) In the plan, it is documented that a 65-year-old...
  15. S

    Medicare Split Visit Question

    There is some confusion of when it is appropriate to split a visit for Medicare IPPE/Initial or Subsequent AWVs utilizing the new E/M MDM if not based upon time for each (IPPE/AWV vs OV) Can a visit be split if all other Medicare requirements are met and the patient has 2+stable chronic...
  16. G

    E/M level

    Our surgeon wants a 99205/99215 for these visits. We cannot seem to find the documentation supporting these levels. Wondering if maybe we are missing something? We are also asking so we can have information from somewhere besides us (coders) to support our decision when trying to educate the...
  17. N

    Unrelated E/M with procedure

    Hi, general question... Is it appropriate to bill an E/M -25 when its unrelated to the primary procedure on every visit? It's not bundled due to both codes being unrelated. For example, patient comes in for debridement 11042 on right ankle, but provider treats edema in another area which is new...
  18. N

    Bundled Office Visit w/ -25

    We have been getting denials recently from Humana when billing 99214-25 (I70.233, F17.218, I89.0) 11042 (L97.312, L97.212, T81.31XA) Dx are different for each code. Only thing I can think of is the i70.233 and L97 codes both address the 'right leg' .. BUT we have been getting paid before with...
  19. KStaten

    E/M for Biceps Rupture

    Greetings Fellow Coders :) Since the E/M level is now based upon MDM only, I have been noticing that providers are still in the habit of billing with the old guidelines in mind, which in some cases, would result in higher levels of E/M. I would really appreciate if others can help me out by...
  20. M

    99211 on same day as injection and pregnancy test

    Hello coders! Please help clarify so I can settle the dispute with the NP and WHNP in my office. A patient came in and was seen by the CMA for pregnancy test and depo injection. The pregnancy was negative. Can we bill a 99211 with the depo injection and the pregnancy test? Please explain...
  21. M

    Do you add MOD 59 to a sono with a Comp (99385) visit?

    Hi, Pt came in for Comp visit 99385 with a pap (Q0091) and TV sono (76830) 99385-25, Q0091, 76830-59? Thank you
  22. KStaten

    Repeat Injections with E/M Codes

    Greetings Fellow Coders! :) Scenario: A new patient is evaluated and found to have OA of the left knee. On that visit, the physician decides to perform an injection and bills an E/M (99203) with a modifier 25. At that visit, the physician does not "plan" another injection. If the patient...
  23. KStaten

    Documentation Requirements for Components of E/M

    Hello Everyone! With the new 2021 E/M Documentation changes, there have been questions that have arisen in regards to requirements for the HPI and Exam. Now that these components are deemed "medically appropriate" by the provider, that leads some to think that the extra the flexibility extends...
  24. L

    Question Using vitals dated the day before on a 99211

    I work for a residential BH company that also provides medical services to the residents. Because the patients are living in such a close environment, the nurses are doing vitals daily, in the evening. The next day, when they bill 99211, the vitals are dated the day before. They were told that...
  25. J

    Question New Patient E/M with injection 20610

    We are finding that new patient office visits billed with injections are being denied as not medical necessary. The injection is being paid . An office visit is performed and Patient is new. 99203,25 was billed with 20610 and the J code Should the 99203 be down coded to 99202 when an...
  26. J

    Question MD and Physical Therapy same day

    Can a patient have an appointment with the MD with xrays on the same day as physical therapy? Same facility different providers.
  27. G

    No qualifying visit?

    Provider is wanting a 99202 for this visit. I do not feel this visit has enough documentation for a qualifying visit. Does anyone see something I may be missing? Thank you Primary Care Provider: Accompanied by: Self Visit Type: New Visit Chief Complaint: Estab care- Requesting labs History...
  28. J

    Question Aetna Medicare Mid-Level E/M

    Our office is having problems with Aenta Medicare (specifically Aetna Medicare Elite and Premier) denying our Physician Assistant E/M charges stating the provider type is ineligible to bill/perform the service (PI-170). They will pay other services on the claim, if any, (like a UA, EKG, etc) but...
  29. KStaten

    Answer Coding / Billing Audio-Only Telehealth Visits

    Hello Everyone! :) Here's my silly question for the day. (Brace yourselves, as I am sure more are to come. ;) ) As I have interpreted from articles, the accepted Telehealth services have been expanded to include audio-only telephone calls, as well. (Yay!) Now this is the part where I am...
  30. T

    Question Physical exam in a Telehealth visit

    Does anyone have information about documenting physical exam for established patient telehealth visits billable using 99201-99215? It would seem a limited exam could be documented based on physician observations during the call. I know it isn't technically required (2/3 elements and all that)...
  31. A

    Question Acceptable ROS/PFSH notation?

    My provider usually documents ROS/PFSH for establish patients as such: PAST MEDICAL HISTORY, SOCIAL HISTORY, MEDICATIONS AND ALLERGIES: Reviewed and not changed since last visit. REVIEW OF SYSTEMS: Reviewed in chart and signed. Per E/M guidelines, the provider has to indicate that the...
  32. C

    2021 E/M Documentation Changes - What are your EHR vendors saying

    Good afternoon AAPC members. I am working to find out if anyone out there is in discussion yet with your EHR Vendor about the changes for 2021 E/Ms. If so, would you mind sharing the name of your EHR Vendor and their level of preparations? Thank you!! Carol J. Self, CPPM, CPC, EMT AAFP
  33. J

    2nd Opinion, fracture, can we bill Office Visit?

    If someone could PLEASE shed some light on this because there are differing opinions in the office. A child was seen by a different practice, he has a broken arm, I am ASSUMING they billed a fracture code. Mom wants him to come see us for a second opinion because they are removing the cast...
  34. J

    Question Separately identifiable E/M

    There seems to be a lot of ambiguity in defining separately identifiable E/M services. We have scenarios where patients were referred to different specialtists (Cardiology, ENT, GI, etc) who come and evaluate the patient. They eventually decide that the pt will have to undergo a procedure (Heart...
  35. A

    Seperatly Identifiable

    We have an encounter that our offices coders dissagree on. We did a procedure after an Office visit. One says because the pt came in for an Office visit and the "decision for surgery" (no global period for this procedure) we should bill the Office visit with a -25 modifier. Another says the work...
  36. M

    Return to work exam

    I'm confused about how to code return to work visits. We get patients who have been off work due to illness and they come in for a return to work exam and form to be filled out. Should this be coded as a preventive exam if the illness is resolved and no other problems are found?
  37. G

    Wiki AWV vs Preventive vs E&M

    We are having a difference of opinion between coders and billers, Coder coded as 99397.GY No HPI Missing updated written screening schedule 5-10yrs Visit qualified as preventive and preventive 99397 is not covered by Medicare Biller wants code changed to 99214 as provider refilled RX looked at...
  38. K

    Question HPI elements

    Good afternoon I have a question in regards to HPI elements for the following example and would appreciate any advise and insight Established Patient visit Reason for visit - HIV Followup Last seen 1.2.2019 CD4 660/30% ,viral load 21 on current meds Dx HIV 2011 . Risk Factor Heterosexual...
  39. J

    Is this a 99204?

    My provider reported 99204. I only see the HPI as a EPF which would bring this to a 99202. Can anyone take a stab at this and let me know what you think? Thanks, Jo ------------------------------------------------------------------------------------------- Chief Complaint: new patient...
  40. M

    Blue Shield CCI Edit Issues

    I am having issues with Blue Shield. If a patient has an office visit and is then sent for labs (in house full service laboratory) on the same day Blue Shield denies the Office Visit as global when a urine dip (81003) is billed by the lab (we operate under one tax ID number) even if we append a...
  41. J

    Two E/M Services, Same Day at Same Clinic, But Two Providers? What modifier??

    Hello! So I work for a clinic, where we have a bunch of different providers who do different things, but they are all under E/M codes. So I just ran into something that I have never seen before. I was entering a 99215 encounter for a provider, and I saw that our EMR system automatically put...
  42. K

    Modifier -25 with 99205

    Is it possible to use modifier -25 with 99205 if psychotherapy is also on the same day as a new patient E/M? Is there a better way to code this? So; 99205 -25, 90838
  43. A

    When can an E/M be coded with 12002

    Hello - Any help or guidance to the information would be great. I am trying to find a document or something in writing that states when the E/M code is appropriate to be with a 12002 and when it is not. Thank you, Aimee ;)
  44. A

    Need E/M Scoresheet for 1995 Guidelines

    Hello - Any suggestions on the best E/M score sheet you have found for 1995 guidelines would be great :) It can be a paper form or interactive. Thank you, Aimee
  45. A

    Urgent Care referred to the ED

    Hello - I need some advice on if this can even be coded. We had a patient present at our Urgent Care that was referred to go to the ED. Is there enough information below to support a 99211? Visit Type: Urgent Care Visit Document Type: Chart Note...
  46. R

    E/M in Urgent Care with Simple Laceration repair

    Is it common to charge an E/M with -25 mod along with simple laceration (dermabond) ? The E/M note is showing all components, however, nothing "above and beyond" is being documented? If not does anyone have a link or source information? Thank you in Advance. Robyn
  47. K

    To bill Preventative or Not to bill Preventative???

    I'm running into issues billing for several of my sites... The doctors will have the CC as "follow-up" or "routine" sometimes even "dm check 6-months" and there is always a full workup but the doctor puts like, 7-10 diagnosis codes in there, usually insignificant things like HTN, DM, obesity...
  48. J

    Secondary Office visit Billed with Annual Physical

    I have a Physician who regularly bills an Annual Physical (99395-99397) with an Office visit E/M(99212-99215). I have tried telling him the differences as to when and how this should be done and for the most part, he has cut down on billing an office visit(99212-99215) with an Annual...
  49. baroquecoder

    RHC E/M w/Vaccine

    Hello! Is an E/M always billed with a vaccination in the RHC? I am being advised that ‘since the doctor has to see the patient in an RHC’ to always bill with E/M, when the sole purpose of the visit is the vaccination... my understanding is that all E/Ms regardless of location must be medically...
  50. A

    Newborn NAS on mophine...considered critical care?

    Good morning- If a newborn (28 days) is being treated in the nicu for NAS (neonatal withdrawal syndrome) with morphine, and no other issues...should it still be coded as critical care? And if so, is there anywhere to find any confirmation (CMS website?) that it should be coded as such? Or...