# When new patient critea is not met.



## aforsythe (Jan 26, 2018)

Hello all,

I am looking for some input/advise on a new patient question.

We had a new patient come into the office for a new problem(we have never seen this patient before). During the visit the provider DID NOT perform an exam. 

In this case would it be acceptable to bill an established patient based on the HPI and MDM or are you required to bill a new patient 99201?

I am looking for any supporting documentation on how to bill instance such as this one.

Thanks in advance.


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## coderlaury (Jan 26, 2018)

*When new patient critea is not met*

Guidelines require that all three areas must meet a certain level to code/bill for that particular level.

In other words a 99201 would be appropriate if there was NO documented Physical Exam Components, as the other two areas would also meet a level 1 New Patient.

The way that I remember it, is that the Provider can only bill/code for the least amount of work done for a new patient.  This also true of the HPI, ROS, PFSH.

Hope this helps
Laury


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## kroemer4 (Jan 30, 2018)

*Thoughts from an Auditing Perspective*

A visit cannot be billed if it doesn't meet the criteria of the code. A 99201 requires at least a PF exam. Did the provider not touch the patient, but "examine" with other senses? Alert & oriented/no acute distress/pleasant appearing/normal gait/speech patterns wnl, etc. can all be collected without a hands-on exam. Did ancillary take vitals? Did counseling/coordination of care encompass more than 50% of the visit? Does another CPT code better support what took place in the visit? What was going on in the visit to lose the exam element?


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## Agilbert3 (Jul 27, 2018)

*Proper query for this situation.*

I am a new coder and my physicians are unfortunately not strong with documentation. My question is if they do forgot to document a physical exam for a new patient, then can/should I query them? I feel that no matter how I word it, it is leading, and they will just mark all physical exam areas even if they don't remember.


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## twizzle (Jul 27, 2018)

*Proper query*



Agilbert3 said:


> I am a new coder and my physicians are unfortunately not strong with documentation. My question is if they do forgot to document a physical exam for a new patient, then can/should I query them? I feel that no matter how I word it, it is leading, and they will just mark all physical exam areas even if they don't remember.



If these are new patients then the services would usually be unbillable without a physical exam. They are not using time statements are they?...even then, a new patient would require a physical exam and it would be unlikely that all new patients are having counseling encounters. Are any of these visits to establish care? In those situations where the whole encounter is counseling there should be no elements of E/M (maybe vitals) because they would not support counseling.

To answer you question, it really would not be a leading query to ask them to do an addendum and add a physical exam. I'm sure, by telling them the service is unbillable without it, they'll sit up and take notice. No exam- no $'s.

The fact that they may mark all areas of the exam is not really your problem but down the line, this could be a compliance problem if they continue to keep doing an addendum. The document should be complete and compliant by the end of the encounter ideally.


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## Pathos (Jul 30, 2018)

All New Patient and Consultation Codes require an Exam, without it you cannot bill a New Patient or Consultation Code. 
If the provider did in fact perform an Exam, then the provider should include it in the patient documentation. 

The practice of marking all exam elements must comply with medical necessity, and is simply fraudulent without medical necessity. 

CMS does allow inpatient initial admits to crosswalk to subsequent visits, however I haven't seen the same crosswalk from New Patient to Established anywhere.

As a rule of thumb, CMS wants all patient documentation to be ready when the chart has been signed and closed in the EMR. There is some leeway in terms of amendment policy, however the more the provider amends and the longer the timeframe; the greater risk of being audited and penalized by CMS/insurance.

So in summary: No exam, no New Patient/Consult visit. The provider can amend notes, but should be aware that improper use will raise flags.


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## caprigrl (Aug 30, 2018)

*Established patient seen for new service.*

Hi all,

I have a question. If an established patient with a physical therapy facility comes in next for a E&M with the DO (working under the physical therapy tax id) . Is the patient considered NEW since they are new to the DO or exisiting since they have been coming to the facilty in the past. 

Thank you for any direction in this area

Sharon  incase I do not see the answer please reply to SHARONBLOM85@gmail.COM


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## thomas7331 (Aug 31, 2018)

caprigrl said:


> Hi all,
> 
> I have a question. If an established patient with a physical therapy facility comes in next for a E&M with the DO (working under the physical therapy tax id) . Is the patient considered NEW since they are new to the DO or exisiting since they have been coming to the facilty in the past.
> 
> ...



Physical therapists are not eligible to bill E&M services, so per the CPT definition, physical therapy would not be considered a professional service for purposes of establishing a patient.  If the patient had not seen this DO, or another physician in that practice of the same specialty, within the last three years, then this would be a new patient visit.


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