Wiki Can New Pt EM be billed with no HPI

[vhuscher]

I have a provider that did not do the HPI, (it was done by RN) and wants to bill a 99203. I has been my understanding that this cannot be billed since both CC and HPI are done by the RN. Another coder said to bill and established pt visit. Could someone please solve this situation.

Thanks

 

[ellzeycoding]

So, Yes, according to CMS, the HPI must be asked and recorded by the provider.

There is a Q&A on the NGS Medicare website that discusses billing an equivalent established patient visit when some required documentation for a new patient visit is missing.

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/evaluation%20and%20management/em-faq_new%20vs%20established%20patients

Question: When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: An initial level of service requires 3/3 elements. If only 2/3 elements are present, the service can be billed as a subsequent service. Updated 6/9/2017



Would all Medicare carriers accept this? No. Would a commercial accept this? No.

But it's an interesting thought...

 

[Lyta2000]

Need to make sure they know that doctors must do HOI.

 

[ellzeycoding]

Update on my previous response...

PREVIOUSLY (prior to 11/13/17), NGS had stated:

Question: When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: In this circumstance, the service can be billed in one of two ways:

a. The provider can elect to use an E&M code from the outpatient “established” series (CPT codes 99211-99215), which will require only 2/3 elements.

b. The provider can elect to use the E&M range code (CPT code 99499), and submit supporting documentation of the service that will be used to price the code.



On November 13, 2017, NGS updated their E/M FAQ and changed their position:

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/evaluation%20and%20management/em-faq_new%20vs%20established%20patients

It now states…

Question: When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: An initial level of service in both the hospital (99221-99223) and office (99201-99205) settings requires 3/3 elements. When one element is not performed for a valid reason (e.g., a patient with dementia cannot provide any history), this must be documented in the medical record and may still be counted toward the appropriate level of coding. Unless there is a valid reason documented for the missing element, initial level of care expectations have not been met and the service is not billable. Updated 11/13/2017



This line of reasoning is more in line with what I had previously known and what other carriers (Medicare and commercial) tend to follow. I thought it was odd that they were recommending an established patient E/M for new patients!