Primary Care Coding Alert

Question: Our office has a policy that patients should come in every three months when they have diagnoses such as diabetes, hypertension, or hyperlipidemia. The visits are mostly to get refills for their medications, and there is usually no complaint. Under these conditions, can we bill an evaluation and management (E/M) visit; and if so, what level should we bill?

Codify Subscriber

Answer: If the sole purpose of the visit is just to refill medication, such that there is no history, exam, and medical decision making (MDM) involved, then you should consider billing 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services) for the service.

However, if the purpose of the visit is medication management, an appropriately higher level of E/M service, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. …) may be reported, as long as the documentation supports it. Prescription drug management, for example, is an example of moderate-risk in terms of MDM, while you can use either the medication management or the status of the patient’s chronic condition(s) as the history of present illness (HPI) with an appropriate review of systems (ROS) helping to define the level of history.