Internal Medicine Coding Alert

Question: A new patient presented for a physician/preventive exam. The patient also had three complex problems that the internist spent 45 minutes examining and discussing. My internist dictated two notes: one for the preventive exam and another for the office visit. He wants to bill for a new patient preventive visit and an established patient visit because he discovered the patient's three problems while performing the preventive exam. Can we do this?


Massachusetts Subscriber

Answer: Proper coding calls for you to report both the preventive and problem-related E/M visit with new patient codes (99381-99387; 99201-99205) because your internist is seeing the patient for the first time. Be sure your internist documents (in both notes) that the patient is new to the office. Also, you should attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the 99201-99205.

Example: If the internist provided a comprehensive preventive-medicine evaluation on a 55-year-old new patient, you would report 99386 (Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient; 40-64 years).
 
For the problem-related visit, your physician's documentation supports billing a level-three visit, so you should list 99203-25 (Office or other outpatient visit for the evaluation and management of a new patient ...). The modifier lets the carrier know that the physician performed a separate E/M service.

Watch out: CMS doesn't pay for preventive-medicine codes 99381-99387, so you should report only a new patient code, 99201-99205, if the patient has Medicare. But if the physician evaluates a patient who is new to Medicare, you may use the agency's new preventive code G0344 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment), depending on the medical documentation.