CODING & DOCUMENTATION

 

Fam Pract Manag. 2019 Sep-Oct;26(5):32.

Author disclosure: no relevant financial affiliations disclosed.

“ESTABLISHED” VS. “NEW” PATIENT CODES

Q

I saw a patient who I thought was established but my billing office says was new because the last visit was more than three years ago. I asked to change my CPT 99214 service (level 4 established patient visit) to 99203 (level 3 new patient visit) but was told that the level of history documented was insufficient to support that code. How should I crosswalk between the codes for established and new patients?

A

Established patient visits require only two of the three key components (history, examination, and medical decision making) to support the level of service reported. New patient codes, on the other hand, require all three. (See the table below.) For example, your 99214 visit may be supported by a detailed examination and medical decision making of moderate complexity but only an expanded problem-focused history. To support 99203, your documentation must support a detailed history. An expanded problem-focused history would limit your service to 99202 (level 2 new patient visit).

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CodeHistoryExaminationMedical decision making

99214 (requires 2 of 3)

Detailed

Detailed

Moderate

99202 (requires 3 of 3)

Expanded problem-focused

Expanded problem-focused

Straightforward

99203 (requires 3 of 3)

Detailed

Detailed

Low

CodeHistoryExaminationMedical decision making

99214 (requires 2 of 3)

Detailed

Detailed

Moderate

99202 (requires 3 of 3)

Expanded problem-focused

Expanded problem-focused

Straightforward

99203 (requires 3 of 3)

Detailed

Detailed

Low

OFFICE VISITS FOR IMMUNIZATION

Q

Can code 99211, “Office or other outpatient visit for the evaluation and management (E/M) of an established patient that may not require the presence of a physician,” be reported when a patient presents for a flu shot?

A

Code 99211 is not typically paid in the situation you describe. Payers who use National Correct Coding Initiative (NCCI) edits will deny 99211 if it is billed on the same date as immunization administration (90460–90461 or 90471–90474) even if the nursing assessment (e.g., blood pressure check) is unrelated to the immunization administration and reported with modifier 25. The codes for immunization administration include the clinical staff work of asking about current health and immunization history (e.g., reactions to immunization), providing the vaccine information statement, reviewing benefits and risks of immunization, obtaining informed consent, administering the vaccine/toxoid, and documenting the vaccination in the medical record and immunization

ABOUT THE AUTHOR

Cindy Hughes is an independent consulting editor based in El Dorado, Kan., and a contributing editor to FPM.

Author disclosure: no relevant financial affiliations disclosed.

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, 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.

 
 

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