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PE elements when charging a level 4 new patient

  1. #1
    Red face PE elements when charging a level 4 new patient
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    Hello, I just wanted to see if anyone knows when charging for an Ortho new patient visit level 99204 does there need to be an 8 element body system exam? I didn't know being a specialty if you had to have the 8 full elements. HPI and ROS are perfect. Thanks

  2. #2
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    Yes, all the elements must be met to give a level 4. I do not code ortho, but I do code for a specialist.

  3. #3
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    Atlanta Perimeter Professional Coders
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    Default Comprehensive exam
    Quote Originally Posted by medicode3 View Post
    Hello, I just wanted to see if anyone knows when charging for an Ortho new patient visit level 99204 does there need to be an 8 element body system exam? I didn't know being a specialty if you had to have the 8 full elements. HPI and ROS are perfect. Thanks
    You either have to do a single system comprehensive exam, which is not defined by 1995 guidelines, or an 8 organ system exam. Another alternative is to follow the 1997 musculoskeletal exam. However, I find most physician think the 1997 exams are not flexible enough for individualization for the patient's problems. You primarily have to prove what you are documenting/providing is a comprehensive exam.

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