Wiki New Patient Annual & New Patient Office Visit

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lindseykelly3191

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New patient comes in to establish care with practice, new patient also has a new problem requiring work.

How do you code it? Coding Intel & AMA both state you can bill both New patient visit codes but they might not both be reimbursed. Of course documentation needs to support an additional E/M code.

Example: 20 year old male presents to establish care with physician. Recently had eye exam wnl, seen by dental regularly, type 2 dm stable on metformin.
Complaints today consist of arm pain for 3 weeks with no known injury.

ROS: denies other than stated above

Exam: Right arm pain on palpation

A&P:
Z00.01- routine labs run for baseline of pt
M79.601- x-ray of rt arm with 800mg ibuprofen prescribed
E11.9- stable, cont on metformin.

Would you code this

99385
99203-25 ?

if yes, why, if no, why?

Thanks!
 
Is this really all that was documented for the visit because I'm having a difficult time seeing the 99385 based on the limited information here when I compare it the official CPT description of 99385:
1699990640544.png​
What labs were ordered, were there any counseling/anticipatory guidance/risk factor reduction interventions done? There should be documentation of an age & gender appropriate exam, but the only exam noted is of the right arm, which is related to his medical complaint of "arm pain for 3 weeks with no known injury." Are we really considering the following a comprehensive history "Recently had eye exam wnl, seen by dental regularly, type 2 dm stable on metformin."

Here is a great AAPC Blog post Recommended Ways to Document and Report a Preventive Visit. Here is an example of should be seen in the documentation for 99385, which is outlined in the above referenced blog post.
1699991644553.png
Your opening line in the post "New patient comes in to establish care with practice, new patient also has a new problem requiring work." doesn't indicate that the patient was being seen for a preventive E&M, just that they want to establish care and have a new problem they want to discuss. Just because a patient comes in to establish care doesn't mean that the services are automatically considered a preventive E&M.

I don't know if I'm totally off base here and maybe some of the E&M coding experts can weigh in on my response, but I know our auditors at the insurance company I work for would have a hard time finding the elements required to bill 99385 in this documentation.
 
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