Question New VS Established claim correction

[kelliricks]

Hello ,
Looking for guidance on an E/M coding issue.

A provider recently opened a new Pain Management practice, and many patients followed him from his previous clinic. He billed them as new patients because he believed a new TIN allowed this. The claims were denied, and I was asked to simply change the codes from new to established while keeping the same level (e.g., 99204 to 99214).

My understanding is that this is not a direct conversion. New and established patient E/M codes have different requirements, so the documentation should be reviewed and the established patient code selected based on the applicable MDM. The provider does not bill based on time.

Am I correct that the notes should be re-reviewed and recoded rather than automatically changing 99204 to 99214? Has anyone dealt with a similar situation?

 

[sls314]

Hello ,
Looking for guidance on an E/M coding issue.

A provider recently opened a new Pain Management practice, and many patients followed him from his previous clinic. He billed them as new patients because he believed a new TIN allowed this. The claims were denied, and I was asked to simply change the codes from new to established while keeping the same level (e.g., 99204 to 99214).

My understanding is that this is not a direct conversion. New and established patient E/M codes have different requirements, so the documentation should be reviewed and the established patient code selected based on the applicable MDM. The provider does not bill based on time.

Am I correct that the notes should be re-reviewed and recoded rather than automatically changing 99204 to 99214? Has anyone dealt with a similar situation?

New and established have the same MDM criteria under the new E/M guidelines. The AMA MDM table shows them in the same line as well: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

If you're leveling based on time, you may be shortchanging the provider. A 99204 is 45–59 minutes, while established patient codes are 99214 for 30–39 minutes and 99215 for 40 minutes or more.

Under the old 1995/1997 guidelines, there were differences in the number of key components required for new versus established patient visits. Once the 2021 office/outpatient E/M changes took effect and MDM was simplified, I happily put all of that out of my head!