Wiki CPT E/M coding

[trishaclark25@gmail.com]

Hi all!!

I am getting ready to take my certification exam and one thing that I struggle with and have struggled with throughout all of my classes is the E/M coding. I have come across a scenario for a new patient where all 3 key components are required, yet only two are listed.

How do I properly code this? Do I use the code that contains those 2 key components?

Thank you in advance for your help!

Trish

 

[Chelle-Lynn]

A New E&M services requires 3 of 3; History, Exam, and MDM. If your documentation only has two components and not all three, then the documentation does not support the leveling of a New E&M.

 

[csperoni]

Well, a new E/M is possible with 2 of 3 components IF the coding is based on time. It might be an unusual circumstance for most specialties. However it would not be unusual for a consulting geneticist seeing a patient for BRCA+ mutation to not do an exam on a patient. The visit would consist mostly of counseling and the note would need to reflect the total time, and that > 50% was spent counseling. If there is no time noted, or counseling/coordination of care is <50% of total time, then a new visit must have all 3 components.