Fam Pract Manag. 2016 May-June;23(3):36.
Author disclosure: no relevant financial affiliations disclosed.
New-patient history requirements
Does Medicare's “Documentation Guidelines for Evaluation and Management Services” require a complete past, family, and social history (PFSH) for all new patient E/M services?
No. A complete PFSH is required only for those services that require a comprehensive history overall, such as level IV and level V new patient office visits. New patient office or other outpatient visits, observation services, initial hospital care, consultations, comprehensive nursing facility assessments, new patient domiciliary and new patient home visits must include all three PFSH elements to support a complete PFSH. A complete PFSH for established patient visits in the office, domiciliary or home, and emergency department requires only two PFSH elements.
Prolonged clinical staff services
When should prolonged clinical staff services be reported, and when does the time begin?
New for 2016, code 99415 is defined by CPT as “Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management (E/M) service in the office or outpatient setting, direct patient contact with physician supervision: first hour (list separately in addition to code for outpatient E/M service).” According to CPT, the total duration of the prolonged clinical staff service has to exceed 45 minutes to be billable. The service should be provided by clinical staff
WE WANT TO HEAR FROM YOU
Send questions and comments to email@example.com, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions
More in FPM
Related Topic Searches
MOST RECENT ISSUE
Access the latest issue of Family Practice Management