# New patient Office visit



## joyce (Aug 5, 2013)

What do you do if the provider did not do an exam on a NEW patient!!! 
I have HPI- EPF, vitals and Mdm- SF, do I bill 99201( 1 bullet for the vitals ) or is it nonbillable?


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## FTessaBartels (Aug 5, 2013)

*No exam for new patient*

The only way you can bill a new patient visit without all three components (history, exam and MDM), is when the majority of the time spent with the patient was for counseling/coordination of care.

In such a scenario the physician must document:
1) total time spent face-to-face with patient
2) time spent in face-to-face counseling/coordination of care (must be >50% of total time)
3) the nature of the counseling/coordination of care.

*For example*
I spent 45 minutes with Mrs Patient today, 35 minutes of which were for counseling/coordination of care related to her recent diagnosis of breast cancer. We went over various options for chemotherapy, radiation therapy and surgery. All her questions were answered.


This kind of note would support coding 99204.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## MnTwins29 (Aug 5, 2013)

In the case of a patient who refused an exam, or it was (allegedly) not performed, I always ask two questions:

1) Were any vitals taken and if so, did the doctor review them?
2) Is there any documentation of the patient's general appearance or some type of observation of the patient noted by the doctor?

If the answer to either question is yes, then there IS an exam as this would be the constitutional element and voila!  You have a problem focused exam.   Not much, of course, but there is at least something that is documented and is part of the exam element.   Means that for a new patient, you would have to code 99201, but it is better than nothing.


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## joyce (Aug 5, 2013)

Thank you, I did have vitals, and that is what I gave him  (1 bullet) PF=exam


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