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New pt: 3 key elements

  1. #1
    Default New pt: 3 key elements
    Medical Coding Books
    I work for a large family practice group, we see many new patients a day. In reviewing the progress notes for accurate E&M levels, I sometimes see that not all 3 key components are met. Since billing for a new patient requires that all 3 components what level of E&M should I use? I was told that I would have to use an established code since only 2 of the 3 components were met.

    Any feedback would be greatly appreciated.

  2. Default
    If a new patient comes in and a det hist, det exam and medical decision making of of low complexity is performed you code 99203 however if the medical decision making is straightforward you have to use 99202. The rule of thumb is that it must meet or exceed the requirements. I hope this helps.

    Verna Rivera, CPC

  3. #3
    Are you saying they are missing one all together?

    I have that occasionally with some of my specialties. They have a great history and moderate or even high mdm but no exam and no time documented. In that case we use 99499 and send them in with the notes to the insurance.

    I wouldn't use an established code because you don't meet the definition of established.

    Laura, CPC

  4. #4
    Yes, normally I can't get anything out of the HPI. Sometimes I recieve minimal documentation as "New patient here to establish care" So at this point I have only met 2 of my 3 key components.

    Also do you find you get paid when you bill the 99499?

  5. #5
    As far as getting paid, not yet, we have some in a review process. I am trying to remain positive though.

    No HPI, huh. What about the new patient preventive codes? If there is no HPI I am guessing there is no problem so that sounds like a more appropriate code set to look at.

    Laura, CPC

  6. #6
    As Laura stated, see if this is preventive.
    However, if it is a sick/problem visit, you need to have a chief complaint. Many times the chief complaint gives at least one HPI, e.g., a patient with lung cancer - location lung, or foot pain - location foot, or high fever - severity(or quality) high. Without a chief complaint you cannot bill, period.
    Karolina, CPC, CPMA, CEMC

  7. #7
    Here is another aspect to consider: Does your provider document all s/he does? Are you involved with provider training? Perhaps they just need to be guided as to how to compose a note to reflect all the work they do and thus can withstand an audit.
    Karolina, CPC, CPMA, CEMC

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