EM Coding Alert

Question: Can we bill 99201-99205 for a patient who comes in to establish care with our pediatrician? The patient is new to our practice and is healthy, with no signs, symptoms, or problems of any kind.

Arizona Subscriber

Answer: If the patient has no condition for your provider to evaluate or manage, you cannot bill a new patient E/M code using 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …). That’s because establishing care does not support medical necessity for the service.

For this kind of visit, you essentially have two choices. If all your pediatrician does is take down the patient’s demographic information and does not perform any elements of an E/M such as an exam or a medically appropriate history, then you could simply not bill the patient or the patient’s payer and write off the visit as good public relations.

If you go this route, and if the patient then returns to your practice for either a sick or a well visit, you can then submit a claim for the appropriate service billed at the new patient level.

The other possibility is that your provider actually performs a well visit upon first meeting the patient. In this case, if the patient has not already had a preventive care visit in that year, you could bill 99381-99385 (Initial comprehensive preventive medicine evaluation and management of an individual …) depending on the age of the patient, along with other appropriate services your provider performs during the course of the well visit, and providing the physician performs an age- and gender-appropriate history and exam, provides age-appropriate counseling for the patient or guardian, and orders labs or age-appropriate vaccinations.