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pinktoona

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I code and bill for Primary Care Physicians and a question came up today. My Doctor performed a thorough exam on a patient for his entrance into the Coast Guard. I am coding this as a 99204 but wondered if anyone has any other information for billing for that type of exam. Thanks so much!
 
Remember New Patient Visits need all 3 Key Components of the E/M Service Documented

Hello pinktoona,

You are correct in billing the office/outpaitent visit code for this patient as I don't think from what you describe a Preventative Service was performed. Just remember that when coding CPT 99204 the documentation needs to support all three key components of the e/m service which is a Comprehensive history/examination and Medical Decision Making of Moderate complexity. Having a comprehensive examination only does not support billing CPT 99204. I would recommend using an E/M Audit tool to score out the level of service appropriately, you can find one online.

Hope this helps~

M.Hannus, CPC, CPMA, CRC
 
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