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Question New pt. level 3 or 4?

wynonna

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FOR ENT: E&M note is: Detailed history, 12 systems/organs or more from 1997 guidelines for exam (detailed) , and Moderate decision making for a new patient would be a 99203 or 99204? and which E&M worksheet tool is best for NEW patients or how can I find it?
Thank you
 

Pathos

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Beaverton OR
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E/M is a fickle creature at best, but there are some help and guidelines out there to help tame the beast. Because CMS has not given us any quantifiable guidelines, but basing them on medical necessity (qualitative), then the auditing becomes very subjective. Some companies (like AAPC), has attempted to streamline the E/M auditing process by implementing the Marshfield Clinic Tool (point system for Medical Decision Making), and while CMS has noticed this tool, they have not necessarily accepted it.

With that said, I can give you some references, reading material, tips & tricks, along with answering any specific questions you might have:

CMS E/M guildelines - I always start out with these as the base line, and then go from there
Local MAC - Depending on where the provider practices, there might be some local E/M guidelines. My MAC is Noridian as I live on the West coast, but will be different if you live in a different state.
E/M University - Another good resource created my an actual MD (and CPC coder). Some of his stuff is free, and there are some you can pay for.
AAPC E/M Online Course - Definitely not free, but another resource if you need a refresher. Also, consider grabbing the E/M Exam Study Guide and/or Practice Exams.
AAPC did a free PowerPoint presentation as an overview. It's from 2012, but could still be helpful.

E/M Audit Tools:

NGS Audit Tool (MAC)
Highmark Virginia BCBS Audit Tool
Novitas Interactive Audit Tool
Novitas Paper Audit Tool


However to directly answer your question, the E/M level always boils down to provider documentation. Based on the information you are providing, the E/M level would likely be a 99203, as the 99204 requirements are as follows:

The documentation for a 99204 requires THREE out of THREE of the following :
1) Comprehensive History
2) Comprehensive Exam
3) Moderate Complexity Medical Decision-Making

Don't forget that in order to bill a New Patient level, the patient has to be classified as a New Patient (less than 3 years of last visit).

Hope this helps!
 

wynonna

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Yes, it helps greatly, and thank you. I have multiple worksheets which I work with and have had different supervisors who see things subjectively. I have a new patient worksheet which yielded a 99203, but I like to verify my coding sometimes when I can. I am currently doing IP consults, which are treated as new patients. I also know Medicare does not accept Consult codes. So we bill 99201-99205.
 

Pathos

True Blue
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Beaverton OR
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You're welcome! Remember when cross walking a consult code to check the patient status New vs. Established. I've had several Consult patients that ended up being an Established patient due to being seen by that provider or someone from their clinic, but with similar credential.
 

twizzle

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Wynonna....you would not bill 99201-99205 for IP Medicare consults which I think is what you are saying. Those are office/OP codes. No, bill 99221-99223 for IP Medicare consults.
 

Pathos

True Blue
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Wynonna....you would not bill 99201-99205 for IP Medicare consults which I think is what you are saying. Those are office/OP codes. No, bill 99221-99223 for IP Medicare consults.
This is true; you wouldn't normally bill an outpatient E/M code for an inpatient encounter. Code either Consult, Initial Admit or Subsequent Visit for the inpatient visit (or Observation if that is appropriate per documentation) instead. My example above was for outpatient visits in general.
 
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