Podiatry Coding & Billing Alert

The initial visit of an established beneficiary in a single specialty group practice setting with a new provider is not a new patient.

You know that inappropriate reporting of E/M levels has been inviting significant scrutiny recently and one especially thorny area is accurately reporting new patient encounters. Follow these key points to correctly identify the complexity levels of new patient encounters from your physician’s notes and recoup your deserved E/M pay.

Good news: Part B MAC Palmetto GBA has given pointers on how to decide the overall level of service for an evaluation and management (E/M) encounter, such as an office visit. It has posted guidance on how to choose medical decision making (MDM) level for you to stay compliant when coding.

Background: To determine the level of MDM, you should assign a levelto each of the three MDM components that your doctor performs. The level in each category determines the final MDM level. There are three elements that contribute to the complexity of the medical decision making: 

• diagnoses/management options, 
• complexity of data reviewed/ordered, and 
• the table of risk. 

You must have two out of the three MDM components score at a particular level in order to assign that level of MDM.

Categorize Each Diagnosis

Start your MDM level assessment by tackling the first category: number of diagnoses. For this category, ask yourself what’s wrong with the patient, and are the diagnoses new? For each diagnosis, you will assign a point and score the diagnosis level as follows:

• Self-limited/minor problem —1 point each, with a max of 2 points
• Established problem, improving/stable — 1 point each
• Established, worsening — 2 points each
• New problem, no planned additional workup — 3 points each, max of 3 points
• New problem, additional workup — 4 points each

So what exactly constitutes a “new” problem? “In most instances, a new problem is one that is new to the provider and being addressed at that visit,” Palmetto said on its website in a June 10 E/M Tip.

“There are two exceptions to this general rule:

• The initial visit of an established beneficiary in a single specialty group practice setting with a new provider
• A visit by an ‘on call’ or covering provider. In these instances, the established problems are treated as if the beneficiary was seen by the unavailable provider.”

“ For example, an established diabetic patient with foot inserts comes in complaining of ankle joint pain. The physician evaluates the patient’s pain and orders lab work and anaspiration (although this cannot be done at the time of service), to investigateinfection and kidney problems. The doctor also orders replacement for the patient’s diabetic foot inserts. The physician has treated one new problem (joint pain w/ additional work-up to rule out contributing sources) and one established (but stable) problem (with corresponding management) — the diabetic shoes.This would be assigned 5 points, scoring “high” for the number of diagnoses category. If x-rays where ordered or taken at time of visit it would increase your points & level of MDM even more,” explains Arnold Beresh, DPM, CPC, Peninsula Foot and Ankle Specialists PLC in Hampton, Va.