New patient visit- no exam


Local Chapter Officer
Sioux Falls, SD
Best answers
I was wondering if anyone had any suggestions on how to bill this.
I have a physician who continually is not documenting his exam on his new patients. We have talked to him about it and he says he will do it but still nothing.
anyway how would you code it with out an exam? New patients visits require that you have all 3 components. Would you lower it to an established patient visit since you only need 2 of the 3 components? or would you leave it as a new patient visit and just give him the lowest level 99201?
Any suggestions/advise would be great!!
I would ask him if he actually did an exam on the patient. If he did ask him to redictate the note with the exam portion on it. 99201 requires 1 body system for the exam. If there is nothing dictated then you can't even bill that.
New pt no exam

The old addage, if it is not documented, it is not done...therefore no payment for the service, no RVU'S, and finally, no payment for the Doctor. Good Luck,
New pt with no exam

Recently, we had the same problem and took it to Medicare. You can not bill without an exam on new patient unless you use time. Also, the CPT E/M guidelines under the title "Levels of E/M Services it states, "Levels of E/M services are not interchangeable among the different categories or subcategories of service." So you can not change it the established patient. In our case we had a consult on a preg mother regarding the fetus and he did not exam the patient. We have asked him to document his time and the reason for the visit and now he bills using time. We have developed a statement on his visit note that states "I spent >50% (____/____) counseling and coordinating the care of this patient in regards to __________________________."

This helps the physician to remember to document. The visits with no exam or time were not billed and that makes the physician correct the future documentation very quickly.

Last edited:
He is doing an exam, he is just routinely not documenting it. he just completely skips over it in his dictation. we have talked to him about it, he says he will fix it but he still is having issues so we are docking all his visits down to the lowest level new patient visit but I dont really feel comfortable even with that since the codes say you need all 3 components. The only thing that I think might be saving me is the nurse is documenting vitals. Can I count that as a point for exam and give him the lowest level then?? any thoughts?
E/M Documentation

I say hold the bills that he is not documenting the exams for and show him the lost revenue. Hopefully he will then see how important it is..

I am having a similar issue with the practice I code for, he is dictating that he did an exam regarding his consults, however; he checks only two systems or areas, with 1 pertinent to the chief complaint,( his hx is usually detailed and MDM is usually moderate or high) which is putting the level of service as a 99252 level 2, because the rule for consults is 3/3 otherwise code to the lowest. His documentation does not support a detail because as I understand, you need 4 findings in the affected area and 4 other areas should be checked with a total of 8 overall ( systems or areas). I have had numerous sessions of educating the physician and giving him coding tips. Do anyone have any suggestions and am I coding this correctly?

The other issue is regards to his new office visits, he discuss patient's HX, ROS, the information he is obtaining is suffcient for a higher level of service, however; he does not document the service he rendered (hx), consequently, putting him at a lower level of service for new patient visits. Any suggestions/ guidiance on coding accurately? Thanks!
INITIAL VISIT after consult in Hospital

How should my physicians code an office visit when the patient was seen in the office for hte first time. However, the patient was first seen by my physician in the hospital. Should this be coded as initial visit or a follow up visit?

Thank you,

Pawan Arya:confused:
INITIAL VISIT after consult in Hospital


How do I code a visit for a patient coming to the Practice first time but was seen initially in the hospital?


Pawan Arya
Asked and answered


How do I code a visit for a patient coming to the Practice first time but was seen initially in the hospital?


Pawan Arya

Pawan ... you asked this on another thread earlier today and it's been answered ...

The answer is the same --- established patient (patient has been seen by the practice within the last 3 years - doesn't matter where patient was seen, as long as service was provided within the last 3 years)

F Tessa Bartels, CPC CPC-E/M
Can we assign 99212 - 99215 for new patient visit document if physical exam not available since patient refused. Please advise.

That would be incorrect coding if the patient was in fact a new patient by the CPT definition.

You really have three choices in this situation - 1) if more than 50% of the time was spent counseling or coordinating care and this is appropriately documented, a code can be assigned based on time; or 2) the provider can document an exam based on their visual observations of the patient and you can assign the new patient code based on this; or 3) you can bill the unlisted E&M code 99499 and submit notes so that the payer can make a payment determination.