Wiki NGS Medicare - New Patient E/M Coding when only 2/3 met... your thoughts

[ellzeycoding]

Came across this from the NGS Medicare site...

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/evaluation%20and%20management

#5

When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: In this circumstance, the service can be billed in one of two ways:

a.The provider can elect to use an E&M code from the outpatient “established” series (CPT codes 99211-99215), which will require only 2/3 elements.
b.The provider can elect to use the E&M range code (CPT code 99499), and submit supporting documentation of the service that will be used to price the code."


The part about using an established code (for a new patient) baffles me and goes against everything I've ever been tought or read...

Your thoughts???

 

[Orthocoderpgu]

When you think about it, it makes sense to change the visit from new to established when one of the key components is missing. Remember, for new patients you must meet all three key factors. Without all three factors (HX, EXAM, MDMD) you cannot chose a code. Period.

So using the two components that you have to chose an established choice is a viable alternative.

 

[ellzeycoding]

Yeah, interestingly, usually a 9920X = 9921(X+1) as far as the coding requirements. The reimbursement is comparible.

Just wonder if any docs would "abuse" this.

Let's say the document everything for a 99205, except they are deficient in MDM. They really only had straightfoward MDM. Technically this would bump them down to a 99202 at the highest. So they ignored the MDM and coded an established based on 2 of 3 key components and were able to get to a 99215 (use a rule of 2 of 3). Hypothetical situation of course, and probably rarely going to happen.

National averages

99202 = $75.73

99215 = $146.43

Again, this entire situation is probably far-fetched.

I'm wondering if there are any other "implications" of a new patient being coded as established in any other areas.

Does anyone know of any other carriers that have the same recommendation as NGS, above?

 

[ellzeycoding]

Update on my previous response...

PREVIOUSLY (prior to 11/13/17), NGS had stated:

Question: When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: In this circumstance, the service can be billed in one of two ways:

a. The provider can elect to use an E&M code from the outpatient “established” series (CPT codes 99211-99215), which will require only 2/3 elements.

b. The provider can elect to use the E&M range code (CPT code 99499), and submit supporting documentation of the service that will be used to price the code.



On November 13, 2017, NGS updated their E/M FAQ and changed their position:

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/evaluation%20and%20management/em-faq_new%20vs%20established%20patients

It now states…

Question: When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: An initial level of service in both the hospital (99221-99223) and office (99201-99205) settings requires 3/3 elements. When one element is not performed for a valid reason (e.g., a patient with dementia cannot provide any history), this must be documented in the medical record and may still be counted toward the appropriate level of coding. Unless there is a valid reason documented for the missing element, initial level of care expectations have not been met and the service is not billable. Updated 11/13/2017



This line of reasoning is more in line with what I had previously known and what other carriers (Medicare and commercial) tend to follow. I thought it was odd that they were recommending an established patient E/M for new patients!