• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

E&M coding - help please!


Local Chapter Officer
Best answers

I am trying to do my first E&M audit - one of my providers saw a new patient to establish and he did an office note which states NEW PATIENT HERE TO ESTABLISH...........
He did a short history.......
He also stated - "Pap not due until July - come in then"
he did speak with her regarding conception plans, LMP, vitals and BMI - this is all documented with an office note.
He also no charged her since he did not do a full exam....my questions is - when she comes back in is she now established or new?



Murfreesboro, TN
Best answers
I think she should be charged because he saw her and he did do somewhat of an exam. I would collect all the data (HPI, Exam, and MDM) that he has and do an e/m level. And that way she would be established when she came back in. But I think the bottom line is that he did see tha pt. Hope this helps!

Jessica Harrell, CPC
Thompsons Station, TN
Best answers

I agree she should be charged. Even if the physician did not do a complete exam, he should be able to charge by time, providing he recorded the amount of time spent with the patient. Then when the patient comes back in she is not considered a new patient.

However, I have had situations like this that put the coder in a sticky spot as to whether the patient is new or established. If the physician insist on not charging her for the first visit, I think you really should still consider her an established patient when she returns.

Good luck!