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Thread: New patient visit- no exam

  1. #1
    Join Date
    Apr 2007

    Question New patient visit- no exam

    AAPC: Back to School
    I was wondering if anyone had any suggestions on how to bill this.
    I have a physician who continually is not documenting his exam on his new patients. We have talked to him about it and he says he will do it but still nothing.
    anyway how would you code it with out an exam? New patients visits require that you have all 3 components. Would you lower it to an established patient visit since you only need 2 of the 3 components? or would you leave it as a new patient visit and just give him the lowest level 99201?
    Any suggestions/advise would be great!!

  2. #2
    Join Date
    Apr 2007
    St. Louis, Missouri


    I would ask him if he actually did an exam on the patient. If he did ask him to redictate the note with the exam portion on it. 99201 requires 1 body system for the exam. If there is nothing dictated then you can't even bill that.

    Melissa Blow, CPC

  3. #3
    Join Date
    Apr 2007
    Seacoast- Dover New Hampshire

    Default New pt no exam

    The old addage, if it is not documented, it is not done...therefore no payment for the service, no RVU'S, and finally, no payment for the Doctor. Good Luck,
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  4. #4

    Default New pt with no exam

    Recently, we had the same problem and took it to Medicare. You can not bill without an exam on new patient unless you use time. Also, the CPT E/M guidelines under the title "Levels of E/M Services it states, "Levels of E/M services are not interchangeable among the different categories or subcategories of service." So you can not change it the established patient. In our case we had a consult on a preg mother regarding the fetus and he did not exam the patient. We have asked him to document his time and the reason for the visit and now he bills using time. We have developed a statement on his visit note that states "I spent >50% (____/____) counseling and coordinating the care of this patient in regards to __________________________."

    This helps the physician to remember to document. The visits with no exam or time were not billed and that makes the physician correct the future documentation very quickly.

    Last edited by Diana Phelps; 02-11-2008 at 02:37 PM. Reason: add another statement

  5. #5
    Join Date
    Apr 2007


    He is doing an exam, he is just routinely not documenting it. he just completely skips over it in his dictation. we have talked to him about it, he says he will fix it but he still is having issues so we are docking all his visits down to the lowest level new patient visit but I dont really feel comfortable even with that since the codes say you need all 3 components. The only thing that I think might be saving me is the nurse is documenting vitals. Can I count that as a point for exam and give him the lowest level then?? any thoughts?

  6. #6


    No documentation on the exam for a new patient. Don't bill it. He is seeing the patients for free. Unless he does time based.
    Last edited by pmlangdon; 02-12-2008 at 04:40 PM.

  7. #7


    I say hold the bills that he is not documenting the exams for and show him the lost revenue. Hopefully he will then see how important it is..

  8. #8

    Wink E/M Documentation

    Quote Originally Posted by AAPCgigibc View Post
    I say hold the bills that he is not documenting the exams for and show him the lost revenue. Hopefully he will then see how important it is..
    I am having a similar issue with the practice I code for, he is dictating that he did an exam regarding his consults, however; he checks only two systems or areas, with 1 pertinent to the chief complaint,( his hx is usually detailed and MDM is usually moderate or high) which is putting the level of service as a 99252 level 2, because the rule for consults is 3/3 otherwise code to the lowest. His documentation does not support a detail because as I understand, you need 4 findings in the affected area and 4 other areas should be checked with a total of 8 overall ( systems or areas). I have had numerous sessions of educating the physician and giving him coding tips. Do anyone have any suggestions and am I coding this correctly?

    The other issue is regards to his new office visits, he discuss patient's HX, ROS, the information he is obtaining is suffcient for a higher level of service, however; he does not document the service he rendered (hx), consequently, putting him at a lower level of service for new patient visits. Any suggestions/ guidiance on coding accurately? Thanks!

  9. #9

    Default INITIAL VISIT after consult in Hospital

    How should my physicians code an office visit when the patient was seen in the office for hte first time. However, the patient was first seen by my physician in the hospital. Should this be coded as initial visit or a follow up visit?

    Thank you,

    Pawan Arya

  10. #10

    Default INITIAL VISIT after consult in Hospital

    How do I code a visit for a patient coming to the Practice first time but was seen initially in the hospital?

    Pawan Arya

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