Coding Consult

A Because you only evaluated the patient's problem and provided a treatment plan the patient could perform herself, you should report the appropriate E&M code (99201-99215). The extent of the documentation that meets the three components-history, exam, and medical decision-making-and whether the patient is new or established will determine the code you choose.

For example, if it's an established patient and you document expanded problem-focused history and low-complexity medical decision-making, you could assign 99213.

Patient status Q During an office visit, I performed an expanded problem-focused history, a problem-focused examination, and low-complexity medical decision-making. Does the patient's status-new or established-affect the level? Which level of E&M service should I report?

A Yes, the patient's status changes the office-visit level, and you would code 99201 or 99213, depending on that status. For established patient visits, you must meet the requirements for only two of the three components. New patient services mandate that you meet all three components.

The documentation requirements for each level are different, too. A level-four established patient visit (99214), for instance, requires a detailed history and exam and a moderate level of complexity. The same level of new patient visit (99204) requires a comprehensive history and examination and a moderate level of complexity.

Report a level-three office visit, 99213, when you spend 15 minutes evaluating an established patient. Report 99201 when you spend 10 minutes with a new patient. Disregard the lowest of the three components when billing an established patient visit.

In the scenario you asked about, you can ignore the problem-focused exam, which leaves you with low-complexity decision-making and an expanded problem-focused history. The two highest components of the visit meet 99213's requirements.

New patient visits require all three key components, so you should report new patient E&M services based on the lowest component. In this case, the physician would use problem-focused exam, which qualifies for 99201.

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