Wiki NEW Patient Office Visit downcoded to ESTABLISHED visit???

Brenda Ray

North Augusta, SC
Best answers
If the Physician fails to meet the 3 out of 3 required criteria for a NEW office patient, is it appropriate to downcode this to an ESTABLISHED office visit? This particular Physician only met 2 out of the 3 required elements...he did NOT do an Exam on a NEW patient and did not document any time factor either. I think it is unbillable but we have been told to downcode it to the ESTABLISHED visit (only 2 out of 3 have to be met) even without the Exam????? I find that hard to believe because for a NEW patient, there should definitely be an Exam and History and MDM for sure.

Thanks for your help in advance!
You can not bill new or established if he did not do an exam on a new patient it is not billable. You can't bill established on a new patient.
That was my thoughts as well. I know with our MAC/FI, we are told to downcode Initial Hospital visits to subsequent hospital if they are a Consult and they do not meet the minimum requirement for level 1 Initial Hospital since there is not a one-to-one match for Inpatient Consults to Initial Hospital visits. However, if the Initial Hospital visit is NOT a Consult and the minimum requirements are not met for a level 1 Initial Hospital, it is not billable.

I would think the same concept applies to NEW patient office visits. If 3 out of 3 are not met and the minumum requirements for at least a level 1 is not met, then it is not billable. We are being told that NEW patient office visits should be downcoded to subsequent visits if the minimum is not met but I cannot find anything on our MACs website to validate that. Just wondered if anyone else knew anything about this.

Thanks for your response!!
It's possible you can report 99499 and let the carrier issue payment based on the documentation.

"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). The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate."

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Rebecca, this is a great reminder of possible solutions for the original poster's inquiry! And since I'm buried in EM studies right now, this is extremely helpful! Thanks for supplying. ---Suzanne E. Byrum CPC