Optometry Coding & Billing 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). 

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])