Wiki E/M new pt vs est pt

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samyjm13

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I have been coding now for 5 yrs, and I have done pretty good coding E/M levels. Now, the orginization where I work tells me that if a new patient doesn't meet all the elements I have to code an established patient level and that is the way they have always done it.
I have always used my audit sheet that I revceived at an E/M audit class I took and have never coded an est. patient level when it was a new patient. Does anybody else code this way or did I miss something? Could use some enlightenment on this.
And please, somebody has to have an opinion on this, sometimes when I ask questions I don't get an answer. Sure could use one on this issue.

Thanks so much!!
samy
 
I'm not sure what you mean. The E&M levels of service for a new patient have the key component criteria that usually can be met from documentation. Are you saying, for example if the patient doesn't meet the lowest level of key components for a new patient: PF history, a PF exam and a straightforward MDM (which is a 99201), you would code down to a 99211?
 
Sorry for not explaining myself, but yes basiclly that is what they tell me, that if it doesn't have all the elements for a new patient that they code it at a est. patient level, because it would meet all elements for an est. patient. I don't feel I am making any sense either. lol

Thanks
samy
 
So for instance if they have only a detailed history, and medical decision making of moderate complexity but no exam they could bill a 99214 since they only needed 2 of the 3? Good question. I would like to see what people think of that as well.
 
I have serious reservations about a policy like this - if a patient is a new patient, then that visit should be coded with the new patient code, regardless of which level that it falls under. Coding a 99214 for a new patient just because the documentation doesn't support 99204 is fraudulent - you are stating that this patient has been seen at your practice by physicians in this specialty when that is not the case.
 
Personally, I haven't seen anything in writing permitting the use of an est. visit in lieu of a new E/M code. CMS does have a citation regarding this...

In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate.

Page 39

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
 
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