# Not enough documentaion for new patient visit, can I bill it as established?



## 13preyabhi (Dec 30, 2016)

Hi,

I have two questions, one can we consider vitals as an problem focused exam when there is no exam documentation?
second, when physician doesn't have not enough documentaion for new patient visit, can I bill it as established patient visit?

Please help me!

Thank you so much,

Preya parekh, COC-A


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## CodingKing (Dec 30, 2016)

You cant pick and choose between new and established. Coding as established when they are really new would be considered downcoding which is a no no.

As to whether vitals alone are enough to count as a single body system Constitutional, I'll let someone else chime in.


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## Jennifer Turner (Dec 30, 2016)

Hi, 

As Coding King stated, you do not have the option to choose if the pt. is New or Established. If the pt. has not received any professional services from the physician or another physician in a group of the same specialty within the last 3 years then the pt. is automatically considered a new pt.... there are no exceptions to that rule. If the encounter was under those circumstances then you must bill New pt...

Also, please understand that you must MEET or EXCEED the components (Hx, Exam, MDM) that are required.. Not sure of the location, but let's just say that you are coding a Outpatient Office Visit, the lowest code that you can use will be 99201. For this code, a brief HPI would have to be performed ( No ROS, or PFSH is required). Your overall History level would be problem focused. 

For your Exam, One body area/Organ system will count as a Problem Focused Exam.. In your case the vitals do fall under Constitutional and depending on the documentation guidelines that you are following 95/97 it depends... *The 95 DG's do not have any rules set on the amount of vitals that have to be obtained.. however, the 97 DG's state that the provider must document at least 3 (BP, Temp, Ht, Wt, etc.) in order for them to count as one overall organ system (Constitutional).*
Your MDM would be considered straightforward, of course considering the elements that go into the MDM component.


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## cdeak01 (Dec 30, 2016)

If you are using the 1995 guidelines then vitals would be enough to support a problem focused exam. The requirements for the lowest level new patient visit 99201 are problem focused history, problem focused exam and straightforward MDM.  If the provider did not document enough to support these minimal requirements I would question the medical necessity of the visit.


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## 13preyabhi (Dec 30, 2016)

*Thank you so much!!*

Thank you so much all! Now I have clear understanding of this. I really appreciate all your help! 

Preya


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