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Billing established patient code for a new patient

eeoo

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Can you bill an established patient office visit if the patient is a new patient, but the documentation does not all three components required for new patient? For example, the documentation would support a 99212(established patient) instead of 99201 (new patient).
 

eeoo

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The documentation does not support 99201, as only two of the three required components are documented. Is it appropriate to code the established patient code (with two out of three components required), even though the patient was a new patient.
 

mitchellde

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No it is not appropriate to code a new patient as an established patient. The patient is a new patient and therefore unknown to the provider, the criteria is set up the way it is because the provider needs minimal amounts of all three key criteria to evaluate a new patient. Your options are:
* have the provider amend the encounter note
* code it as unlisted E&M
* do not bill the encounter
 

RADCODER

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Monmouth
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mitchellde- Would you be willing to share your resources? This question has come up amongst my co-workers and we wonder what if a new patient does not meet 3/3 requirements, usually the exam is missing, HOW do you code it? I have looked for documentation and have come up empty every time.

Thank you.
 

Bjohnse1

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I agree with mitchellde. The description of the code alone should tell you the correct way to bill. NEW patient or ESTABLISHED patient. We are allowed to choose codes that come closest to describing the services provided, but only when there is no clear code for what was done. In this case, there IS a clear code for new patient office visits, so you should not be choosing a code that you feel may be a better fit billing-wise. IF you are having trouble meeting the criteria for a new patient office exam, but this was a new patient, then maybe the doctor/office should look at a better way of documenting in the future.
 

savgrr

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I know this is an old thread, but this issue has continuously come up at my office. Can someone provide some articles and references for this? I'm trying to present it to my office manager.


Savannah Robinson, CPC
 

CodingKing

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The CPT book list the guidelines and sets the definition of what is considered a new patient and what is considered an existing patient.

Its also pretty clear in the code description whether the code is for a new patient or an established patient.

You cant just pick and choose what is considered a new patient and what is an established patient, you must follow the written guidelines.

By picking a code that says the patient is Established you are certifying that the patient truly meets the definition of an established patient.

I cant remember exactly what page in the CPT book it is but there is something that states you must select the code that most accurately describes the service performed. Based on that guideline alone, The code description says new patient, you cannot substitute the word new with established. The same goes for Established you cannot replace the word with new. The reason Established only need to meet 2 of 3 is because the information should already be on file so there is no need to start from scratch and there isn't a need to do as comprehensive of a visit.
 
Last edited:
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Location
Rio Grande Valley, Texas
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mitchellde- Would you be willing to share your resources? This question has come up amongst my co-workers and we wonder what if a new patient does not meet 3/3 requirements, usually the exam is missing, HOW do you code it? I have looked for documentation and have come up empty every time.

Thank you.


Just wondering..
Are the vitals documented on in-take?

If you have at least 3 of the 7 vitals documented then you have at a minimum a "Problem-Focused" exam.
**Constitutional Organ system for the '95 DG
 

CodingKing

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