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Fam Pract Manag. 2009;16(3):28

Cindy Hughes is the AAFP's coding and compliance specialist and is a contributing editor to Family Practice Management. Author disclosure: nothing to disclose. These answers were reviewed by the FPM Coding & Documentation Review Panel, which includes Robert H. Bosl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Emily Hill, PA-C; Kent Moore; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC, MHA.

New or established patient?

Q If all of your previous visits with a patient have been for acute care and then the patient makes an appointment for a physical, can you bill that as a new patient physical?

A The preventive medicine service codes define new and established patients the same way the other evaluation and management codes do. A patient is only new if you or another physician of the same specialty within your group practice has not provided professional, face-to-face services to the patient within the past three years.

Welcome to Medicare physical requirements

QIs a Welcome to Medicare physical required for all new Medicare patients?

ANo. The exam is a benefit to Medicare patients in their first 12 months of enrollment. However, there is no requirement to provide this service.

What is “normal”?

Q If I document that an organ system is “normal,” how many bulleted elements does that cover?

ABoth the 1995 and 1997 versions of Medicare's Documentation Guidelines for Evaluation and Management Services allow for describing organ systems as “normal” or “negative.” However, the Centers for Medicare & Medicaid Services' Evaluation and Management Services Guide has this to say: “A brief statement or notation indicating ‘negative’ or ‘normal’ is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). (However, an entire organ system should not be documented with a statement such as ‘negative.’)”

It's also important to consider that, for a detailed or comprehensive general multisystem exam, the 1997 guidelines require that you document at least two bulleted elements for each organ system or body area examined.

Taking all of this into account, it seems prudent to document at least two bulleted elements as normal or negative rather than making a single statement for an entire organ system when using the 1997 guidelines.

Medicare e-prescribing

Q We have been using e-prescribing for almost a year with few problems. The Medicare initiative is confusing, though. Most patients are on multiple medications. Refills are rarely synchronous with the visit. Do only new prescriptions count? Do refills count? If so, when do we attribute them?

A The Medicare e-prescribing program is confusing. Reporting is based only on prescriptions produced during a face-to-face encounter. Therefore, you do not need to report phone refills. This document on the Medicare Web site provides the simplest instructions available for the program. For more information about e-prescribing, see the recent FPM article, “E-Prescribing: Why the Fuss?."

Editor's note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD-9 manuals and the Documentation Guidelines for Evaluation and Management Services for the most detailed and up-to-date information.


Send questions and comments to, 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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