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Thread: New Pt visit without exam

  1. #1

    Default New Pt visit without exam

    AAPC: Back to School
    One of our physicians saw a new patient but didn't do an exam. How would you bill this service to Medicare? Is it even billable if all 3 (History, Exam, MDM) aren't documented?

  2. #2


    Non billable if no exam. New and consults need all 3 things meet. You were right, I have been there before.

  3. #3

    Default new patient

    you can code it as an established patient visit

  4. #4


    no, you bill an unlisted e/m and send along the notes. they determine payment from there.

  5. #5
    Join Date
    Apr 2007
    Woodland Hills, CA


    No, you can't code it for a new pt visit.

    Per Medicare telephone conference, the 3 elements MUST be documented for new or est. visits. For est. visit you only need 2highest, but 3 must be there. I doubt, you can code even for est. pt visit.

    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  6. #6
    Join Date
    Apr 2007
    North Carolina


    I agree with AR...unlisted

  7. #7

    Question IC,

    In the CPT code book it states "All of the key components (i.e. history, exmaination and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of service". The New Patient E/M Services are further defined by " requres 3 components" (99201).

    Isn't there a nice Medicare biller/coder who can clarify this for us?

  8. #8
    Join Date
    Apr 2007
    North Carolina


    99201 still requires an exam portion...example:

    A new patient with a bee sting

    CC : “My finger hurts”

    HPI: Patient was gardening this morning and was stung by a bee on the left index finger. The pain was initially quite severe, but has begun to improve.

    Physical Exam: left index finger is red and warm with a small punctuate lesion surrounded by mild induration.

    No periungual inflammation.


    1) Simple bee sting


    1) Ice pack for 1 hour, then Neosporin and a bandaid

    Since the original question was directed at "lack of an exam"...99201 could not apply.

    When AR suggested an unlisted code...that's really all you have to go with UNLESS...

    The E/M guidelines do have a specific provision to allow physicians to use TIME as the controlling factor to determine the level of care in certain circumstances. In these instances, the physician MUST spend the entire allotted time face-to-face with the patient AND at least HALF of that time must be used for “counseling and coordination of care.” If you choose to code based on time, you MUST record the duration of the encounter in the record, AND also state that over half the time was spent on counseling and coordination of care. In addition, the nature of the counseling and coordination of care must be documented.

    We have a fertility specialist who often doesn't perform any exam due to the nature of the business. This is when time can be applicable; however, proper documenation is critical

  9. #9


    Well said Rebecca

  10. #10
    Join Date
    Apr 2007


    At least sometimes you have vitals that were taken...
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

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