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Thread: Unable to Obtain the Exam

  1. #1

    Question Unable to Obtain the Exam

    AAPC: Back to School
    Does anyone know if there is guidance on whether the physical exam elements can be caveated? For example, a patient presents with severe psychosis and is unable to respond to a psychiatric/physical examination which is required for the psychiatrist to be able to bill a CPT admission code (99221-99223) based on the 1997 psychiatry exam elements.

  2. #2


    If you are looking to bill the admit codes, 99221-223, you could do the following-
    1) Can the MD atleast get some vitals? I would think that in lieu of the MSE, he could comment about his psychosis and why he cant respond. That in itself is part of the exam. The patient is obvisouly not oriented, so that could be a bullet there.

    If you cant/dont use one of those for the exam and you have absolutely no exam elements at all, then you can bill either a 99499 with documentation (which is what Medicare says to do) or you could bill the 9922_ with 52 mod for some other carriers. I have also heard of people bumping to the subsequent category (99231-3) but I dont personally. The intent of visit isnt a subsequent

  3. #3


    Many thanks...that is what I was thinking. The only other possibility would be based on the total inpatient floor time involved in the coordination of care for the patient if the documentation is present to support the time for the 9922_ code.

  4. #4


    I think you would still have to have atleast some of each element to meet criteria of code. I dont think you can just skip one area and still code based on time. I could be wrong though..

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Coding based on time

    1073358 writes: I dont think you can just skip one area and still code based on time.

    Actually when you are using counseling/coordination of care to determine your level of service, the ONLY things you must document are:
    1) total time spent face-to-face with patient
    2) amount of time spent in counseling/coordination of care (must be >50% of total time)
    3) the substance of the C/C

    If the patient is unable to participate in the medical decision making, then time spent with the family (or designated decision maker) can be counted, but you must state a medically necessary reason for the patient not participating (in this case - severe psychotic episode).

    No other key elements are required.

    F Tessa Bartels, CPC, CEMC

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