No intake

JuarezD

Contributor
Messages
21
Location
Concord, California
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0
Question,

I have an NP asking me the following question for coding,

I saw a new patient to LL today, we’ve not done an intake yet and visit was pretty straight forward because they had an emergent problem and I sent them off to the ED. Since we will eventually be seeing them to do a comprehensive new visit I am guessing we will still code that at 99204 but for today’s visit should I be billing 99201 or 99202?


I want to say nothing to be billed since there was no intake. Am I correct? We are an FQHC facility.

Thank you
 

Chelle-Lynn

True Blue
Messages
729
Location
Modesto, CA
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0
You can only code a new visit one time. Being an FQHC Facility does not change this guideline and all regular E&M leveling requirements remain in place.

So you would need to level todays visit based on the guidelines for a New Visits (99201-99205). You will need to see if the documentation meets the requirements for leveling the visit (history, exam, MDM). If yes, bill as above. Their next visit to your office would be considered an established patient and would be leveled based on the established guidelines. 99212-99215.

If the documentation does not support leveling the claim, then you are correct and no E&M would be billed and their next visit would be considered their first visit.

Always follow the coding guidelines for your FQHC Facility. :)
 

arrana

Guru
Local Chapter Officer
Messages
105
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I agree with the new patient and leveling aspects of Chelle-Lynn's answer, but what about billing the encounter at all if there are no intake forms? Is it legal/compliant to bill a visit if the provider doesn't have completed/signed patient registration forms on file?

We have similar issues at our FQHC. For various reasons, we have patients who are seen and treated but we don't have (or can't find) the initial registration forms. Can we bill for these visits?

Thanks,
Arrana
 
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