Coding Consult

August 4, 2006

E&M services

When reporting most E&M services, you need to know two things: (1) Is the patient new or established? (2) What are the documented levels of history, physical exam, and medical decision-making (MDM)?

Here are quick instructions on how to make these decisions so you can select the correct E&M level every time.

Face-to-face time matters

Let's say a patient comes to you (an FP) complaining of headaches. Last year, he had seen your partner, also an FP, with a URI. You have to use an established patient code. The patient was seen within the last three years by another physician of the same specialty in your practice.

And location isn't an issue. If your practice has multiple locations and a physician in location A sees the patient in January and a physician at location B sees the patient in December, the patient is still established. The fact that the practice had to create a new chart is inconsequential, Hammer says.

But say you examine a patient whom another physician in your practice dealt with the previous year. However, suppose this other physician provided no face-to-face service; he simply interpreted some test results.

In this case, you can consider the patient to be new when selecting an initial E&M code, says Kathy Pride, a consultant with QuadraMed in Port St. Lucie, FL.

Exceptions for different specialties

There is a way for you to report a new patient visit even though two physicians in the same practice had a face-to-face visit with the patient within a three-year period. That occurs when you're in a multispecialty practice and the two physicians are in different specialties, says Cindy Parman, with Coding Strategies in Powder Springs, GA.

For example, a gynecologist in your multispecialty practice sees a patient in 2004 for irregular periods. In early 2006, the same patient sees you-an internist-for shortness of breath. Because the gynecologist and you, the internist, are obviously of different specialties, you may report your initial visit with the patient using the new patient codes, Parman says.

Or take a patient who's been seeing a pediatrician in your multispecialty group. The patient is now 18 and wants to transfer her care to you, an internist. When she sees you, she'll qualify as a new patient even if you're treating her for an existing problem that the pediatrician treated at her last visit two years ago.

How to select an E&M range

Once you've determined whether the patient is new or established, you should use that information-along with the type of E&M service provided-to select the appropriate E&M code range.

For instance, let's say you (an internist) provide an office visit for a patient with persistent heartburn and stomach pain. You've already determined that he's an established patient.

Go to the "office or other outpatient services" portion of CPT and find the code range for established patients, which is 99211-99215. This is the range from which you'll make your final code selection.