Wiki Need Verification on New Pt Visit

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jifnif

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I wanted to get another opinion b/c I have two separate sources telling me two different things. If I have a new pt visit and it is a 99204 by all components except for history should I bill the pt a 99201 or does it fall to an established pt visit? Say a 99213? I know there are no notes here but I need to know for all situations that apply if not all three components are met. Thanks!
 
New patient E/M's require all three key components be met to determine the E/M level. I think the only way you would have 99201 is if you have no ROS in the history component. Otherwise, without actual documentation, I think you probably have a 99202.
 
Well, here is my problem: I audit charts for one job and for another job I get audited. During my job where I get audited I had a pt visit that was new but it was lacking a comprehensive history. Due to no history component I reassigned a 99201 from a 99204. My QA told me that it no longer is a new pt e/m but now moves to an established visit code b/c it is missing the history component. I have also had another auditer tell me that I was correct. Please someone verify! Thanks.
 
I also am an auditor and I would have down coded the service to a lower level New patient as well instead of an established patient. I guess to me, a new patient is just that, a new patient.

Did the documentation have at least location, duration, context, etc. and is there at least one ROS? If so, then maybe 99202??
 
jifnif said:
Well, here is my problem: I audit charts for one job and for another job I get audited. During my job where I get audited I had a pt visit that was new but it was lacking a comprehensive history. Due to no history component I reassigned a 99201 from a 99204. My QA told me that it no longer is a new pt e/m but now moves to an established visit code b/c it is missing the history component. I have also had another auditer tell me that I was correct. Please someone verify! Thanks.
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You state it was lacking a comprehensive history...was there no history at all or did it just not meet the comprehensive requirements? You can have a 99202 with an EPF history and 99203 with a detailed history. So I think what we need to know for this situation is what was truly missing in the history component.
 
jifnif said:
For the entire history component I had only a brief HPI. No ROS or PFSH. Sorry for the confusion. :)
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This certainly does not qualify for even a 99201*. I can see why there is confusion here. They are telling you to go to the established patient codes because you only have two of the three components, and that's all you need for those codes. The problem is I don't think that is a valid answer either, since this patient is not established! This may end up being a non-billable encounter due to the missing information.

*I have changed my mind on this... see below!
 
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NP visit vs Established

First, I agree with all who say that you can NOT downgrade to an established patient visit code.

If you have a problem focused HPI but no ROS or PFSH, that immediately translates into the 99201 as your highest possible level of service. As long as you have an examination and medical deicision making of at least problem focused (exam) and straight forward (medical decision making), you absolutely DO meet the requirements for 99201.

If you have a comprehensive examination and medical decision making of high complexity, the HPI is the pivotal point. The minute that there is absolutely no mention of ROS, you are sunk...it is your chief complaint (eg: Pain in the low back for 1 week)...you have a chief complaint and duration. No matter how you bump and grind this, it goes no where beyond a 99201.

Coding - the art of frustration...

Have a wonderful evening...
 
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I have re-read the documentation guidelines and now have to change my answer. I agree with AuntJoyce.. this DOES qualify for a 99201. My bad! Thanks AuntJoyce for correcting me!
 
jifnif said:
For the entire history component I had only a brief HPI. No ROS or PFSH. Sorry for the confusion. :)
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Then you simply have 99201 based in a problem focused history. I would not code to the established levels since those requirements are different and would get you to 99214 with a PF hx, Comp exam, and moderate MDM. That would be upcoding the visit.
 
Thanks to everyone who responded. Now the question would be, how do you tell your QA that they are wrong? This is a new job. Anything that comes back from the payor as my error (even after it is checked by QA) is 20% off of my pay.
 
WPS Medicare says that if you don't have enough documentation to support even a 99201, then you should code a 99499 and submit notes to them
 
jifnif said:
Thanks to everyone who responded. Now the question would be, how do you tell your QA that they are wrong? This is a new job. Anything that comes back from the payor as my error (even after it is checked by QA) is 20% off of my pay.
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Print out a copy of the 1997 E&M Guidelines and walk them through the documentation. You can't come up with anything other than 99201. You can use the New vs. Established patient diagragm in the CPT book to get you to the correct section... Good luck!
 
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