Medicare Compliance & Reimbursement

Question: The physician started an established patient on a new drug. Two weeks later, the patient presented for her next appointment, and one of our non-physician practitioners (NPPs) evaluated the patient, taking blood pressure and other vitals. The NPP also asked the patient if she had experienced side effects since she started the new drug. The report indicates that the visit is specifically for checking how the patient is adjusting to the medication. What E/M code should I report for this encounter?

Answer: Your code choice, as always, hangs on your documentation. If an NPP (ARNP or PA) provides care, you could have a 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) service, assuming your documentation supports that code.

Or if the clinical staff (RN or CMA) under the direction of an NPP or MD provides the care, you may have a 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services ...) service.

Regardless of the E/M code you use, don't forget to report the ICD-9 codes for the diagnosis the medication is intended to treat and the codes for any side effects the patient mentioned at the visit.

Key: A patient who has just started a new medication regimen usually reports to the physician by the latter's order. These scheduled visits are often 99212 encounters, but could be higher-level if complications arise.

Try this: The following documentation may help support  claims for medication checkup E/Ms:

• A record of patient's blood pressure, if relevant, and other vital signs
• A note indicating the clinical reason for checking blood pressure or other vital signs
• A list of the patient's current medications (include level of patient compliance, if possible)
• Proof that the physician evaluated the clinical information the NPP obtained and made a management recommendation for the patient.