Wiki CPT vs Medidare rules...


San Tan Valley, AZ
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I am curious to hear how other coders get to a new patient level with CPT rules.


When considering the HX, PE and MDM for a new patient level which level of elements do you require for the following:

For example using CPT RULES to code a 99204 do you require a COMP HISTORY, COMP PHYSICAL EXAM and A MODERATE MDM level?

OR would you allow a comp hx, comp exam and a low MDM level to count for a 99204? Or comp hx, detailed exam and moderate MDM level?

The difference in opinion can have a HUGE impact on new patient levels.

What is your view point - pls provide specifics as to what element levels you look for or require your codes to use.

Thank you.
New patient codes require 3 of 3 to be met - the History, Exam and MDM all must meet the level specified in the code definition. If any one of those is not met, you cannot use that level. For 99204, you need a comprehensive history and exam, and MDM moderate. The only exception to this is if you're coding based on time.

There are different ways of determining the level of each key element depending on the guidelines or audit tool you are using, but the code definition is still the same - there's no way to get around that.