Primary Care Coding Alert

Question: A family physician fills out a form for a new patient. The doctor doesn't obtain the patient's history. Which ICD-9 should I use with which level of service (99201-99204)?

Colorado Subscriber

Answer: For the FP completing the form, you should report 99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form).
 
Warning: Don't code the service as a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...). Codes 99201-99205 require all three key components: history, evaluation and medical decision-making. Because you indicate that the family physician didn't take a history, you should not use these codes.
 
Assuming the FP made no problem-related diagnosis, you should link 99080 to the appropriate V70 code. For instance, you should report completion of an adoption, life insurance or college form with V70.3 (General medical examination; other medical examination for administrative purposes).
 
Payment for the paperwork completion depends on the insurer. If the patient's insurance company considers the service noncovered, you may make payment the individual's responsibility.