Primary Care Coding Alert

Question: An established 66-year-old patient presented to our provider. She did not state a specific complaint. The doctor ordered a basic metabolic panel, venipuncture, a dipstick urinalysis, and a complete blood count with differential. Her results came back showing nothing abnormal: the urinalysis dipstick with leukocytes was negative; nitrite negative; urobilinogen: 0.2; protein: trace; pH: 6.0; blood: negative; specific gravity: 1.030; ketone: negative; bilirubin: negative; glucose: negative; the appearance was clear and the color pale yellow. The basic metabolic panel notes that glucose is 98; BUN: 12; CA: 9.0; CRE: 1.0; NA: 140; K: 3.9; CL: 103; and TCO2: 24.

What level evaluation and management (E/M) code should I report for this encounter?

New York Subscriber

Answer: The level of E/M in this, and any, encounter depends on the history, physical exam, and level of medical decision making (MDM) the provider documents, which is not clear from your question. When none of these things is present in the note for an established patient, the only level of E/M that can be reported is 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 ...) since the descriptor does not reference history, exam, or MDM. Even then, the note should reflect that some evaluation and management of the patient occurred.

In this case, as you point out, even a chief complaint is missing from the note. A chief complaint is integral to a visit note, and requires a concise statement, usually in the patient’s own words, of some symptom, condition, or diagnosis that is the reason for the visit. Without it, there is no justification to bill for an E/M, and even 99211 is probably off the table for this visit.

So, you may only be able to report the laboratory services your practice performed, and assuming your practice did the tests ordered by the physician, your bill should only reflect something like the following:

• 80048 — Basic metabolic panel (Calcium, total)
• 36415 — Collection of venous blood by venipuncture (or other appropriate code, depending on the type of venipuncture performed)
• 81002 — Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy (or other appropriate code describing the specific dip stick urinalysis performed)
• 85025 — Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count.