Wiki New Pt-Scant Document

[alewis]

Hello. I have been auditing for years; I audit for a multi-specialty group. I am auditing E/M's and came across a patient encounter-pt hasn't been seen by ANY of our providers-classic new pt visit. The visit doesn't meet the code criteria for any new pt visit (no PE). I need support, documentation, references; should this be considered a non-billable visit or can it be coded as an established pt visit? I've only encountered these scenarios at my current place of employment- I have deemed past E/M encounters non-billable but have not been able to find definitive rules on this subject.

 

[mitchellde]

You may not bill a new patient as establish, this looks like a non billable encounter if you cannot meet even the most basic of the 99201.
The support for this is a new patient is clearly defined as one that has never been to that physician /practice. You cannot elect to bill as an established when clearly they are not. The reason the established criteria is easier to meet is that the patient has been there before and there is historical data available for the physician to review so that certain elements do not necessarily need to be repeated for good care but cannot be counted if not performed. A new patient has no such data for the physician to referr to so all element must be performed for it to be a visit.