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Preventive with E/M Code

  1. Default Preventive with E/M Code
    Medical Coding Books
    My question is: If a new patient comes to the office for a preventive service and there is an acute visit also -would the acute visit be a new patient ie. 99201-99205 or an established 99213 - 99215. According to the CPT Assistant - When a patients presents for a "new" visit the patient would be new until they leave the office. Is there a more up to date policy. Thanks

  2. #2
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    New pt seen for a physical and E & M 99381-99384 (kids) 99385- 99387 (Adults) will use 99201 - 99205 with the 25 modifier on the E&M, Pt new for this visit.

  3. #3
    Location
    Dover Seacoast New Hampshire
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    1,970
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    Sorry, I disagree. A patient can be new only once within a three year period. The preventive visit is coded as a new patient, with the office visit as an established patient, with the -25.

    As always, I welcome discussion! Pam
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  4. #4
    Location
    Overland Park, KS
    Posts
    1,166
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    I respectfully disagree. Per CPT definition, a new patient is one who has not received professional services within three years. If a new patient presents for a preventative exam and an additional complaint is addressed in the same encounter, three years has not gone by. So they would still be considered a new patient. You would report both as new patient encounters. CPT Assistant address this very issue in the October 2006 issue and states plainly that both encounters in this situation should be reported with a new patient preventative E/M and a new patient office/outpatient E/M code.

    This is how CPT advises you would report this type of encounter, but third-party payers may have different reporting requirements, so I would suggest you consult with this specific payer.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  5. #5
    Location
    Dover Seacoast New Hampshire
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    1,970
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    In order to bill the new patient office visit with the new patient preventive, you'd have to double dip in the exam component to meet all three key components.

    Is this now acceptable?

    We typically ask our providers to clearly document HPI elements that correspond with Assessment/Plan details in order to support an established OV. Any lab/rad/medicine data must relate to the complaints in the HPI, and we also expect to see significant additional work. That is, of course, the criteria for appending the -25.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  6. #6
    Location
    Greeley, Colorado
    Posts
    2,045
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    I agree with Pam. Although there has been a lot of discussion on this scenario in the past and most of us have agreed to disagree on how we view it; payors usually will not pay for two new visits on the same day. A patient is new once on that date, so the preventive is new and the problem-oriented would be established.
    Lisa Bledsoe, CPC, CPMA

  7. #7
    Location
    Overland Park, KS
    Posts
    1,166
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    Pam,

    I do see your point....but,

    If the additional complaint was indeed significant and required an additional E/M, then in most cases would you not have separate key components? To me a separate complaint would be (in most cases) a separate exam (although it may be limited), so you would not necessarily be douple-dipping.

    While I do understand Pam and Lisa's point of view, three years has not elapsed between visits,couple that with CPT guidance, and both encounters would be coded with new patient prevenative and new patient office visit E/M codes.

    Again, your payer may see it in a different light, but this is how CPT recommends it is to be done.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  8. #8
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    We are a Pedi practice and when we bill for a new pt health check (preventive visit) and a separate E/M, we charge the established E/M. Some of our carriers will not pay for a new separate E/M.
    Jutta Whipkey, CPC

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