Internal Medicine Coding Alert

Question: During an office visit, my doctor performed an expanded problem-focused history, a problem-focused examination, and low-complexity medical decision-making. Which level of E/M service should I report? Does the patient's status, new or established, affect the level?

Washington Subscriber

Answer: The patient's status changes the office-visit level. That's because you must meet the requirements for two of the three components for established patient visits, but new patient services mandate that you meet all three components. And the documentation requirements for each level are not identical. A level-four established patient visit (99214), for example, requires a detailed history and exam and a moderate level of complexity.  The same level of new patient visit (99204) requires a comprehensive history and examination and a moderate level of complexity.  

Report a level-three office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient ...) if the physician evaluated an established patient. You should report 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient. Disregard the lowest of the three components if billing an established patient visit. In the above scenario, you may ignore the problem-focused exam, which leaves you with low-complexity decision-making, and an expanded problem-focused history. The two highest components of the visit meet 99213's requirements.

New patient visits require all three key components, so you should report new patient E/M services based on the lowest component. In this case, the physician uses problem-focused exam, which qualifies for 99201.