Internal Medicine Coding Alert

Question: Dr. B sees a 68-year-old patient, who has generalized osteoarthritis in her shoulder, for the first time, and performs detailed history and examination, as well as low-complexity medical decision making, during an E/M service. The patient's file indicates that Dr. C, another internist in our practice, interpreted an emergency department chest x-ray for the same patient a year ago. However, Dr. C did not meet with the patient face-to-face. So for Dr. B, is this a new or established patient?

Kentucky Subscriber

Answer: If Dr. C provided no face-to-face service during the ED encounter, then Dr. B can consider this a new patient (99201-99205). If a physician within the group practice of the same specialty provided the patient with a face-to-face service within the past three years, however, you would consider the patient established (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ... ).

So double-check the patient's record to be absolutely sure that Dr. C did not provide face-to-face service during the ED episode. If there was no "face time," report the following for Dr. B's service:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the E/M

• 715.01 (Osteoarthritis, generalized; shoulder region) appended to 99203 to represent the patient's arthritis.

-- Answers to You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.