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 [...]