thressat
Contributor
Does a new pt E&M have to coded as such if the documentation does not support that level or can you use the established codes ?
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Wiki New vs Established
- Thread starter thressat
- Start date
dadhich.girish
Guru
No, it should always be supported by documentation.
RebeccaWoodward*
True Blue
If the documentation can't support the lowest level, 99201, then I recommend an unlisted code; 99499.
"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. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose."
30.6.1
http://www.cms.gov/manuals/downloads/clm104c12.pdf
"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. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose."
30.6.1
http://www.cms.gov/manuals/downloads/clm104c12.pdf