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New patient with Well Visit and Sick

  1. Arrow New patient with Well Visit and Sick
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    Provider seeing a new patient for a complete CPE and also patient has an acute sinusitis. Have billed the 99385 and do I bill 99203 or 99213?

  2. #2
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    If the provider has seen this patient before "Face-to-Face" within the 3 year threshold, or another provider in the department, then the patient should be considered an Established Patient. If it has been longer than 3 years since last visit, then a New Patient level would be more appropriate.

    Now, whether the patient's insurance accepts the CPE and E/M service on the same day is a different subject altogether.


    Source:

    Noridian (MAC) New vs. Established
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  3. Default
    The patient is new to the practice so it is correct that the 99385 is billed, but I have one manager telling me that I need to use 99213 for the sick visit (all components are there to do both visits and insurance accepts) but I have another manager telling me I would use 99203 so I am trying to find out on my own which is the correct coding.

    Ellen

  4. #4
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    My AMA 2018 CPT Standard book says:

    "If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. ... The appropriate preventive medicine service is additionally reported."

    So I take this to mean the order of which procedure you bill really matters, also the reason for the visit. In your example (complete CPE), 99385 should be billed first and then, if the E/M components and medical necessity agree (significant enough), 99213 because the 99385 was also billed.

    If the reverse, (main reason for visit: problem visit) then perhaps 99203 w/ M25 and then 99395.

    Hope this helps!
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  5. Default
    The patient is new to the practice so it is correct that the 99385 is billed, but I have one manager telling me that I need to use 99213 for the sick visit (all components are there to do both visits and insurance accepts) but I have another manager telling me I would use 99203 so I am trying to find out on my own which is the correct coding.

    Ellen

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