Gastroenterology Coding Alert

Question: A new patient presented in our office. Past medical, social, and family history were obtained. The provider documented a comprehensive HPI and a complete (10) ROS. The diagnosis was moderately complex and there was data management. However, no physical exam was done other than vitals being taken. The provider did not document face-to-face time spent with patient. Can I bill more than a 99202?

Wisconsin Subscriber

Answer: For a new patient, the level designation is determined by all three of the key elements: history, examination, and medical decision making (MDM). Therefore, even if you have a comprehensive history and high complexity MDM, but only vitals, you can still only report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …). In your case, with only vitals taken, you can only report 99201 despite a comprehensive history and moderate MDM.

Vitals alone is only one bullet per 1997 guidelines and only one system/body area per 1995, so for either one, this is a problem-focused exam, which limits new patient coding to 99201.

To get to 99202 (… an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …), you would need an expanded problem focused exam, which is 2-7 systems. To get to 99203 (… a detailed history; a detailed examination; medical decision making of low complexity …), you would need a detailed exam. And if the provider had done a comprehensive exam, you would have 99204 (… a comprehensive history; a comprehensive examination; medical decision making of moderate complexity …) based on a comprehensive exam, comprehensive history, and moderate MDM. But unfortunately, you’re stuck at 99201 due to only vitals for the exam portion.

For a new patient with basically no provider exam, it seems that the encounter was likely spent on counseling and/or coordination of care. If that is the case, there isn’t anything you can do about it at this point, but you should educate your provider on when he can (and should) bill based on time spent with the patient, and what he needs to document to be able to do so.