Wiki New Patient Vasectomy Visits

[KaylaRieken]

So when I started here I was told that a new patient that came in to discuss vasectomy was coded 99203 if the documentation was there, but it was never a 99204. These patients are getting scheduled for the procedure. Does anyone have any information why it couldn't be coded as a 99204 if the documentation is there? I heard it was hard to get the 4 elements in the HPI.

 

[Chelle-Lynn]

We are a Family Planning Clinic site that routinely evaluates for and performs vasectomies. There is no restriction for the E&M leveling based on the reason for the visit. If the documentation supports a level four then it would be appropriate to bill this new patient E&M level.

You may want to go back to your management and discuss their reasoning for this original instructions. Often times we hear the response "this is what we have always done." Hopefully with additional education there can be a meeting of the minds at your office and a new understanding can be provided.