Primary Care Coding Alert

Question: A patient met with our physician to discuss his need for a scooter. He denied any types of musculoskeletal problems or weakness, and had no chief complaint. After the examination, the doctor determined there was no need for the patient to have a scooter at this time. We billed 99213 with diagnosis V70.5, but the payer denied the claim as “routine.” Should we have billed the visit as preventative?

New Mexico Subscriber

Answer:  Billing the encounter with 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 …) implies that the patient had some problem for which he visited the physician. This was not the case, based on the diagnosis and the fact that the patient did not have a chief complaint. Without a chief complaint, there is probably also no history of present illness (HPI) (since there is no present illness on which to get a history), and with no chief complaint and HPI, you can’t document even a problem-focused history. There’s also likely no medical decision making, per se (at least in a CPT-context) in such an encounter. So all you’re left with is an exam, which, by itself, does not support a 99213. 

An established patient preventive visit code (99391-99397, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient …) is probably closer to the mark, given the lack of chief complaint, although this encounter does not fit the typical encounter associated with even those codes. If the patient was new to your practice, you would choose from 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient …).

Consider: Another option could be the preventive medicine counseling codes (99401-99404, Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure] …), since this visit is really about having the conversation regarding whether or not the patient needs a scooter as a risk factor reduction (to avoid falls, maintain health and activities of daily living, etc.). In this case, you may also want to use a diagnosis from the V65.4x (Other persons seeking consultation; other counseling, not elsewhere classified). Viable options might include V65.43 (Counseling on injury prevention) or V65.49 (Other specified counseling) to reflect the counseling nature of the encounter instead of V70.5 (Health examination of defined subpopulations), which is exam focused and doesn’t necessarily apply to this situation. The payer may still deny the encounter, but the CPT^® and ICD-9 codes will better sync up and reflect the nature of the encounter if you follow this logic in your coding.