Wiki 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!
 
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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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.
 
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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