Orthopedic Coding Alert

Question: My orthopedist's notes indicate an expanded problem focused history, a problem-focused examination, and low-complexity medical decision making. Which level of E/M service should I report? Does the patient's status, new or established, matter when I'm picking the level?

Texas Subscriber

Answer: Yes, the patient's status changes the officevisit 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. And the documentation requirements for each level are not identical.

A level-four established-patient visit (99214), for example, requires two out of the following three: a detailed history, detailed exam, and moderate complexity medical decision making (MDM), assuming that you have medical necessity for a level-four established-patient visit. The same level of new-patient visit (99204) requires all  three key components including a comprehensive history, comprehensive examination and a moderate complexity MDM (also assuming you have medical necessity for a level-four new-patient service).

In the example described above, 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.

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 components of the visit meet 99213's requirements.

You should report 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient. 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 physician performs a problem-focused exam, which qualifies for 99201.