Wiki New patient with procedure

[aburley77]

Hi,

We have a walk-in clinic with POS as 11, and will treat any person that comes in. Our MD saw a 6 yr old with a foreign body in her nose and used forceps to remove it. He is using 99203 because we have never seen the patient before and 30300 for the procedure. The note only documents the patient coming in to have the procedure and no other conditions or reasons for the visit. Can you bill the 99203 with mod 25 and the 30300? I told the MD no but want to double check.

Thanks!
Annette

 

[mitchellde]

even with a new patient the provide must document a significant Evaluation in addition to procedure perform. the assessment necessary to perform the procedure is not considered a significant evaluation, so even though it is a new patient, it does not sound like you have met the criteria for a visit level in addition to the procedure.

 

[aburley77]

Thanks so much! I really appreciate the help