Otolaryngology Coding Alert

Question: During an office visit, my otolaryngologist performed an expanded problem-focused history, an expanded problem-focused examination and straightforward medical decision-making. Which level of E/M service should I report? Does the patient's status, new or established, affect the level?

Washington Subscriber

Answer: Because established patient visits require only two of the three components, whereas new patient services require all three components, the patient's status will change the office-visit level. If the patient is an established patient, the visit qualifies for a level-three office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient ...). You should report 99202 for a new patient.

For an established patient, you may disregard the lowest of the three components. In the above scenario, you may ignore the straightforward medical decision-making, which leaves you with an expanded problem-focused history and an expanded problem-focused examination. The two highest elements meet 99213's requirements.

Since new patient visits require all three key components, you should report new patient E/M services based on the lowest component. In this case, the otolaryngologist uses straightforward medical decision-making, which qualifies for 99201-99202. Because he also performs an expanded problem-focused history and an expanded problem-focused examination, you should code a new patient visit with 99202.