Ophthalmology and Optometry Coding Alert

Question: Can I use modifier 52 on 99201 if my provider only captures history and MDM for a new patient office visit?

Oregon Subscriber

Answer: In the rare circumstance when your physician provides a service that does not reflect a complete CPT® code description for a new patient encounter, you must report the service as an unlisted service with 99499 (Unlisted evaluation and management service). 

Because new patient encounters require addressing three of the three key components, and if your urologist does not perform one of them (either history, examination, or medical decision making), you cannot report the service with a code from the 99201-99205 range (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components ...). Instead, you’ll need to use the unlisted E/M code. 

Your payer will likely ask for a description of the service provided in the form of the provider’s notes. The payer has the discretion to value the service based on the physician’s documentation when the service does not meet the full criteria and terms of a CPT® code description (for instance, only a history is performed).

If the service provided to the patient involved counseling and more than 50 percent of the total face-to-face time between the provider and patient, you may be able to report the level of E/M based on the total time. Documentation must be present in the medical record to support billing and requires:

• Total time of the face-to-face encounter;
• Total time that involved counseling; and
• Detailed description of what the counseling consisted.

Pitfall: You should not use modifier 52 (Reduced services) with an E/M code. Medicare does not recognize modifier 52 for this purpose, according to CMS Manual (30.6.1 — Selection of Level of Evaluation and Management Service [Rev.1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10]).