Wiki New Patient with no exam

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Frances Kirk

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If a new patient comes in for an office visit but the provider does not perform an exam, it would not meet requirements for a new patient level. Can you then bill an established visit level 99211-99215? Does anyone know where we can find documentation to support the answer.
 
no you may not as the patient does not meet the definition of an estb patient. The fact that the patient is estb is why those visit levels need only 2 of the 3 key components met. If there is no exam you have no visit.
 
You can also use time if it was documented for new patients. I would hope that it is since there was no physical there must have been counseling. Unless the patient walked out, I have had that happen before, we didn't bill anything for those visits.

Or you could use the unlisted E/M, 99499.

Laura, CPC, CPMA, CEMC
 
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