Medicare Compliance & Reimbursement

Financial fallout can be considerable if you eschew new patient codes too often.

For medical practices, the biggest difference between a new and established patient evaluation and management service is simple: money. Service-wise, new and established patient visits often differ little: the new patient E/M often includes simple tasks such as, "setting up a new chart and quizzing the patient a little closer to get familiar with him," explains Quinten A. Buechner, M.S., M.Div., AAPC:CPC, BMSC:ACS-FP/GI/PEDS, ACMCS:PCS, PHIA:CCP, PAHCS:CMSCS, president of ProActive Consultants, LLC in Cumberland, Wis.

Bottom line: When you report a new patient E/M, it pays out at a higher rate, Beuchner says.

Keep in mind, however, that the level of service requirements are more stringent with new patients who are required to meet or exceed the chosen level in all three E/M components; established patients must meet or exceed E/M level in two out of three components.

Let's say you code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...) when you could have reported 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...).

Payout: The 99204 code pays about $152 per encounter. Conversely, 99214 pays about $98 per encounter. That's more than $50 missed if you mistakenly report 99214 instead of 99204.