# Choosing E/M level



## timiket (Sep 8, 2008)

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


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## dmaec (Sep 8, 2008)

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}_


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## RebeccaWoodward* (Sep 8, 2008)

http://emuniversity.com/Level3NewOfficePatient.html

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf


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## ARCPC9491 (Sep 8, 2008)

timiket said:


> 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.


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## tennislaurie (Sep 28, 2008)

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.


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## dwmt1 (Oct 1, 2008)

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


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## dmaec (Oct 1, 2008)

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.


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## dwmt1 (Oct 1, 2008)

Donna- Thanks


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## FTessaBartels (Oct 1, 2008)

*Depends on the level*



dwmt1 said:


> 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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