Oncology & Hematology Coding Alert

Question: We are reporting an E/M encounter for a follow-up patient when our provider did not perform a physical examination for the patient though he obtained a complete history and recorded vitals. In addition, he prepared a detailed treatment plan for the patient. Can we report this as E/M service?

Virginia Subscriber

Answer: You have clarity that your provider is evaluating an established patient. If you look at the descriptors for “new” patient E/M codes and “established” patient E/M codes, you will notice that established patient E/M codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...) need only two of the three components of history, examination and medical decision-making. However, the codes for new patient evaluations, i.e., 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components ...) need all three elements to be performed by your clinician.

Since your clinician has recorded history and documented the treatment plan (medical decision-making) and the patient is an established patient, you won’t need the physical examination for you to report an E/M code for the visit. However, in this case it does state vitals were recorded. Therefore, the exam would qualify as a problem focused examination and allow for the third element to support a new patient visit. Since the examination was recorded, you would report a 99201 since all 3 components must meet or exceed the level of service billed. Any new patient code above a 99201 would require a higher level examination be performed and documented.