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Eli's Rehab Report

Reader Question:

Billing for New Patient with No Exam

Published on Fri Mar 01, 2002

Question: Our physiatrist saw a patient today for rheumatoid arthritis. She had been to the practice before, but not for this problem. After talking with her for about half an hour, the physiatrist discussed several non-surgical ways she should try to improve her condition (such as changes in diet, lifestyle, exercise, etc.) before any more serious treatment. Since he didnt examine her, how do we bill for this? Is this 99213 for a new patient visit?

Texas Subscriber
 
Answer: Although the physiatrist did not examine the patient, you can still base the level of service on the amount of time that the physician spent with the patient, since counseling comprised more than 50 percent of the visit. (Remember, CPT states,If counseling or coordination of care dominates [more than 50 percent] the physician/patient and/or family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service.) For instance, if the physiatrist spent 30 minutes with her, of which only ten minutes was used to document her history, test results from her rheumatologist, and discussion of her symptoms (no physical exam occurred) and the remaining 20 minutes was counseling, the doctor can legitimately bill 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 25 minutes face-to-face with the patient and/or family).
 
This visit must occur face-to-face, as opposed to a discussion with the patient over the phone. Face-to-face is defined as the one-on-one time the physician spends with the patient alone or the patient and family together, including obtaining a history, performing an examination, and counseling. However, during this visit, time can also be reported for reviewing records and tests, arranging for further services, and communicating, in writing or by telephone, with other professionals and the patient (as long as the patient is present).
 
It should be noted that the coding scenario would change if the patient were not suffering from a diagnosed condition. In your case, the patient has rheumatoid arthritis (714.0), which will be a legitimate diagnosis to submit with your E/M code. But many times, patients present to physiatrists for general discussions of ways to lose weight or prevent arthritis. This, of course, would be considered a preventive visit, which Medicare will not reimburse. If you are billing such a visit to a secondary or private insurer, or require a denial with an ABN form so the patient will pay for the visit, you should code it using 99402 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 30 minutes). The diagnosis should be coded using the appropriate V code for counseling (in your case, V65.41, exercise counseling).

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