Down Coding from New to Established for Documentation Reasons

danielawhit

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I am wondering if in a clinical setting you can down code from a new patient to an established patient if documentation does not support a new patient code?

For example: John Doe is seen and the provider documents HPI and MDM but does not document an exam.

I am aware this is not good documenting and provider education has been given but I'm still working on the charts that cannot be fixed.

I appreciate your feedback!
 

CodingKing

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Nope. You don't get to choose new vs established based on the key components that are more favorable. The reason established only requires you to meet or exceed 2 of 3 is its assumed you already have some of the other components from previous visits.
 
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danielawhit

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Thank you!

The only reason I even considered it is because I know with inpatient coding if you don't have the required documentation for an initial admission you can down code to a round if the documentation supports it.
 

jdibble

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Thank you!

The only reason I even considered it is because I know with inpatient coding if you don't have the required documentation for an initial admission you can down code to a round if the documentation supports it.

In the inpatient setting you can down code an initial admission to a subsequent visit only if the provider is the consulting provider. Medicare allows this because when they stopped accepting consult codes they needed a way to account for a low level consult - which would be more equivalent to the documentation requirements of the subsequent codes.

If the provider is the admitting doctor, he/she would need to document enough to meet at least the lowest level admit code - 99221. If the documentation does not support this code, it is recommended to use the unlisted E/M code 99499 to bill for what was done.

The following is an excerpt from CMS Claims Processing Manual, Chapter 12:

"In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed)."

In the case you have, if the doctor did not do an exam, but spent more than 50% of the visit in counseling and coordination of care and has documented that correctly, they could also bill based on time. However, I am assuming in this case that was not done so either the visit is unbillable or you could try to bill it with the unlisted code.
 
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