Neurosurgery Coding Alert

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

Washington Subscriber

Answer: The patient's status does change 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. 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. 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 elements 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 surgeon uses problem-focused exam, which qualifies for 99201.