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specialty e/m guidelines???? confused

  1. #1
    Default specialty e/m guidelines???? confused
    Medical Coding Books
    after talking to some other specialty dr's our physician has asked us to start billing all new patients under 99205 as the e/m guidelines are different for a specialists? i've never heard of this is this true? can we legally bill ALL new patients under 99205? he was also told by some that they bill their new patients under 99455?????? this cant be right. i am now sooo confused any input would be greatly appreciated

  2. Default
    Quote Originally Posted by michellelgrd View Post
    after talking to some other specialty dr's our physician has asked us to start billing all new patients under 99205 as the e/m guidelines are different for a specialists? i've never heard of this is this true? can we legally bill ALL new patients under 99205? he was also told by some that they bill their new patients under 99455?????? this cant be right. i am now sooo confused any input would be greatly appreciated
    Hi Michelle,

    What the physician said to you is based on his belief. You know as much as I do that there are other factors that determine a service of that level. Yes you may have a comprehensive history, comprehensive exam, but what about medical decision making or medical necessity? Remember, medical necessity should be the driving factor for the visit. Does this doctor order a round of tests or review and summarize old records for all his new patients? Is the diagnosis that he is dealing with complex? These are things to keep in mind...

    Good luck :0)

    GeminiCoder74

  3. #3
    Location
    Kansas City, MO
    Posts
    431
    Default
    Silly physicians! They hear the craziest stuff and start seeing dollar signs!

    No, there are not special guidelines for specialists...unless they are thinking of 97 guidelines with specialty specific exams.

    To get a 99205, you need a HIGH MDM, and not every patient is gonna have that.
    You cannot bill every patient with the same code. Not only will the documentation requirements not support every patient for the same exact code, but would set off some serious red flags (repeat/pattern billing)


    99455 is for an exam for a disablity determination....so again unless your practice is that specific, you cannot bill that code on every patient.

    There is always the option of billing for time to get a 99205 when the HIGH MDM is not there...but again, can't work for every patient.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  4. #4
    Location
    Professional Coders of SW MI
    Posts
    5
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    Legally 99205 for all is not appropriate. If this provider is under the same tax ID as the other specialists he spoke to, technically the patient is not new (specifically with medicare patients).
    Also what the other reply states about medical necessity is key. A 99205 for a sprain would be a hard sell for any carrier.
    Colleen M. Rexin, CPC

  5. Default
    Maybe the physician heard only part of a comment or conversation, in that it has to do with what coverage a patient has. Most coders know that as of 2010 Medicare no longer allows consultation E/M's so they have to bill with NP E/Ms. He would still have to meet all the documentation requirements.

  6. #6
    Default
    I know if you don't have something nice to say don't say anything at all but its Friday and I can't help myself.

    Specialists are more than welcome to code all thier visits as 99205 as long as they are prepared for all their outfits to be prison orange.

    Do what needs to be done, document what you do, and code based on documentation. It doesn't matter what specialty you are, the same rules apply to everyone using these codes.

    Laura, CPC, CPMA, CEMC

  7. #7
    Default
    what is the 97 guidelines you speak of " the specialty specific exam?" thats probably what he is talking about

  8. #8
    Location
    North Carolina
    Posts
    3,126
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    Unsure of what specialty you work for but the different exams begin on page 16 of the 97 DG's link. Page 2 gives you the actual pages for each.

    https://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf

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