PE elements when charging a level 4 new patient

medicode3

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Hello, I just wanted to see if anyone knows when charging for an Ortho new patient visit level 99204 does there need to be an 8 element body system exam? I didn't know being a specialty if you had to have the 8 full elements. HPI and ROS are perfect. Thanks
 

VRock

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Comprehensive exam

Hello, I just wanted to see if anyone knows when charging for an Ortho new patient visit level 99204 does there need to be an 8 element body system exam? I didn't know being a specialty if you had to have the 8 full elements. HPI and ROS are perfect. Thanks
You either have to do a single system comprehensive exam, which is not defined by 1995 guidelines, or an 8 organ system exam. Another alternative is to follow the 1997 musculoskeletal exam. However, I find most physician think the 1997 exams are not flexible enough for individualization for the patient's problems. You primarily have to prove what you are documenting/providing is a comprehensive exam.
 
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