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e/m level for addiction intake done by PCP

  1. Question e/m level for addiction intake done by PCP
    Medical Coding Books
    When a pcp does an addiction intake in the office, such as to admit pt to a treatment facility, ie detox, sober house...but is not doing an actual full physical exam (just family hx, personal hx, substance abuse hx, bp,rr, etc) would they still use a new or existing patient code?

    They are attempting to bill as new or existing level 5, but I am not sure the documentation will really support this.
    The same Pcp will be seeing pt weekly while they are in the sober house, but records show that the initial is mainly a extensive paperwork intake and counseling not really a physical exam. ( I have verified this with the OM who states the physical exam usually takes place at the 2nd visit, once the patient is going through withdrawl symptoms) However they do not document the time taken for visit or counseling within the paperwork.

    They are seen weekly after the inital for withdrawl symptoms and urine sampling.
    However they do not document the time taken for visit or counseling within the paperwork.

    I have never had to code such and just want to be sure I am doing it correctly.
    Jill Martin, CPC

  2. #2
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    Quote Originally Posted by JULY694 View Post
    When a pcp does an addiction intake in the office, such as to admit pt to a treatment facility, ie detox, sober house...but is not doing an actual full physical exam (just family hx, personal hx, substance abuse hx, bp,rr, etc) would they still use a new or existing patient code?

    They are attempting to bill as new or existing level 5, but I am not sure the documentation will really support this.
    The same Pcp will be seeing pt weekly while they are in the sober house, but records show that the initial is mainly a extensive paperwork intake and counseling not really a physical exam. ( I have verified this with the OM who states the physical exam usually takes place at the 2nd visit, once the patient is going through withdrawl symptoms) However they do not document the time taken for visit or counseling within the paperwork.

    They are seen weekly after the inital for withdrawl symptoms and urine sampling.
    However they do not document the time taken for visit or counseling within the paperwork.

    I have never had to code such and just want to be sure I am doing it correctly.
    Jill Martin, CPC
    Are these facilities considered "In patient"? If so, then when your PCP admits a patient during an office visit you do not bill an admit code (99222 or 99223). The weekly visits after that sounds like subsequent visits (99232, etc.). There should always be documentation. If there is no documentation then you can not bill for the services.
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  3. Default
    They are billing either established pt 99214,99215 etc, or if patient is new to them new pt code 99204,99205.
    Is this correct? I am confused by this, as they are not doing an actual full exam on this inital visit.
    For subsequent visits the patient comes to the office for a urine test and followup for withdrawl symptoms and they are coding as est pt 99213-99215.
    I just started here yesterday and was not comfortable signing off on these until I was sure.
    Thanks for your help.
    Jill Martin,CPC

  4. #4
    Default
    For established patients it is possible to support a 99214 or 99215 without exam, there are probably some elements such as vitals, general apperance, and some psych components I would think. At the very least you would need a comprehensive history and moderate (99214) or high (99215) MDM.

    For new patients, they are 3 of 3, so you either have to have a comphrensive history, exam, and moderate (99204) or high (99205) MDM, or time must be documented. Another concern with time though, it can not include time spent filling out paperwork.

    Laura, CPC, CEMC

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