Wiki Coding New Patients as Established because of lack of documentation

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01456518N

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I need an expert's advice. Is there ever a legal justification for coding a new patient as an established patient because the doctor didn't provide sufficient documentation to code a new patient? I wish I could give a specific example, but I am a new coder who was told that this was the practice at a certain hospital. Could someone please give me guidance on the compliance of this situation?
 
Nope, that would be downcoding. They must be established patient in order to go for 2 of 3. Anything else would be going against the guidelines. You must select the code that most accurately describes the service provided.
 
Missed Provider Education Moment?

CodingKing sums it up accurately.

Is there a way you can speak with someone who told you this decision and explain that if they are a new patient even if the documentation is lacking that they have to be billed as a New Patient?

You're looking at potential civil and criminal problems if you go through with what they told you.

Best of luck.
 
Thanks for the Responses

This is good to know. Could anyone give me advice on where this could be reported if it becomes necessary? I was "let go" because I was questioning this practice. Any thoughts?
 
Another Question

What would be the proper way of handling new patients who don't have the necessary documentation to be coded as a new patient? Is sending it back to the provider the only way to deal with this?
 
Question for Stephanie

Could you please explain why there are both a yes and no answer to this question? I'm not sure I understand the difference. This isn't the same as new vs established, right?

"Can I submit a subsequent hospital visit if my documentation does not support one of the three levels of an initial hospital visit?
Answer:

Consultant
Yes. If the minimal documentation requirements for the initial hospital visit (CPT codes 99221-99223) have not been met, the appropriate subsequent hospital visit (CPT codes 99231-99233) may be submitted.

Principal Physician of Record (Admitting Physician)
No. If the minimal documentation requirements are not met the principal physician of record (admitting physician) may submit the unlisted E/M CPT code 99499. Do not submit a subsequent hospital visit.

Note: Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment."
 
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Hi Just Wondering,

You could pose this question to the local MAC as to why there is a difference. I can only speculate that they feel the "Admitting Provider" should be meeting 3 of 3 on the initial admit.
 
Follow-up question for Stephanie

Because there is no difference between "new" and "established" patients in the hospital, my original post about coding new patients as established patients wouldn't apply in the hospital setting, correct?
 
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