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Choosing E/M level

  1. Default Choosing E/M level
    Medical Coding Books
    What is the correct way to choose the E/M level service. Example: If you have a Problem focused History, Comprehensive Exam and Comprehensive Medical Decision Making for a New patient visit. Would you choose the lowest level 99201 since it's a problem focused history or 99203 taking it down one level since you have meet 3/3 for a new patient and I only have 2/3. Is there a guideline published regarding choosing the level of service where I can see a black and white answer. Please help

    Timea Toth, CPC, CIC
    Urology Practice

  2. #2
    Location
    Duluth, Minnesota
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    1,133
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    yes, it would be taken down to the 99201 - the guideline "is" you need 3 of 3 for New Patient or Consult.

    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  3. #3
    Location
    North Carolina
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    3,126

  4. #4
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    Quote Originally Posted by timiket View Post
    What is the correct way to choose the E/M level service. Example: If you have a Problem focused History, Comprehensive Exam and Comprehensive Medical Decision Making for a New patient visit. Would you choose the lowest level 99201 since it's a problem focused history or 99203 taking it down one level since you have meet 3/3 for a new patient and I only have 2/3. Is there a guideline published regarding choosing the level of service where I can see a black and white answer. Please help

    Timea Toth, CPC, CIC
    Urology Practice
    Unfortunately you would have to use 99201 - it's in any CPT book - E/M University is also a wonderful resource.

    It seems to me that if you have a comprehensive exam and high medical decision making, you should have more than a problem focused history. The documentation for a PFH is so minimal that virtually every problem could qualify for this.

    Is this due to lack of provider documentation? (i.e. no PFSH, no ROS, etc.) If so, I would educate your provider on how to obtain a proper history from a compliance standpoint. Show him/her that you have to code 99201 - when it really should be a higher level and why....more importantly tell them about the reimbursement differences, that'll get them listening.

  5. Default
    Generally, providers have new pt's fill out a questionnaire/form that serves as a review of systems that the physician then reviews with patient, etc. so perhaps this was not done or not found in the chart. At any rate, for those visits needing 3/3 components to assign an E/M code, just remember that you can only charge as high as the lowest level.

  6. #6
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    Okay but for New Patients and Consultations, do you need all three PFSH to be documented?

  7. #7
    Location
    Duluth, Minnesota
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    dwmt1 - for new or consult - you'd need 3 of 3 components (History/Exam/MDM)
    You can have only 2 PFSH and still have a "new" patient or consultation -
    The level of est/new or consultation is determined by three main components, again - the level of HISTORY, level of EXAM and level of MDM.
    Donna, CPC, CPC-H

  8. #8
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    Donna- Thanks

  9. #9
    Location
    Milwaukee WI
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    4,466
    Default Depends on the level
    Quote Originally Posted by dwmt1 View Post
    Okay but for New Patients and Consultations, do you need all three PFSH to be documented?
    That depends on what level of E/M you're trying to meet.
    Level 1 or 2 new patients or consults - No PFSH is needed

    Level 3 new patient or consult - you need at least one item in any one of the PFSH areas (so if you have a past med hx you're okay)

    Level 4 and 5 new patient or consult - you need all three PFSH (at least one item in each of them)

    You might want to sign on to emuniversity.com to learn more about E/M services.

    F Tessa Bartels, CPC, CPC-E/M

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