Make Sure You’re Not Missing Legitimate Revenue from New Patient Visits
What CPT® evaluation and management (E/M) code would you assign this fictional patient office visit (adapted from one discussed in an MDCodePro video lecture)?
A former patient you last saw four years ago limps into your office, complaining of severe pain in his left knee. It started a week ago when he fell while raking leaves and won’t stop. When straightening his bruised left leg, he grimaces in intense pain. You take a comprehensive physical and comprehensive history, order an x-ray and blood test, call his current primary physician to review his medications, document all of your findings, and prescribe an analgesic.
Will you be billing CPT® code 99205 after this visit?
If not… why not? The higher code means a more accurate record of your patient’s condition and the care you gave him. And, if you’ve properly documented the visit, the code will mean more revenue for your practice.
But “sickest” doesn’t necessarily mean the same thing as “at death’s door.”
Let’s look at a few factors in this hypothetical case that show why it meets level 5 office visit criteria. As we do, you’ll get a sense of how MDCodePro’s methodology and best practices position you to code for maximum accuracy, full regulatory compliance, and all appropriate revenue you deserve for the services you provide.
Know Your New Patients
Code 99205 applies to new patients. But some new patients, like our imagined knee patient, whom we last saw four years ago, have familiar faces.
Physicians used to take the word “new” at face value. In the past, writes Emily Hill, PA-C, for Family Practice Management, a new patient “was someone you had not previously seen or perhaps someone for whom you did not have a current medical record.”
But how do the CPT® billing guidelines define a new patient? As “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.”
Even if a patient is someone the physician or the practice has treated before, if that treatment took place more than three years ago, she or he is a new patient for medical coding purposes.
You’ll want to double-check for “wrinkles” in some situations. For example, as the AAPC’s Michelle Dick points out, a “professional service” in E/M vocabulary refers solely to face-to-face services. Interpreting EKG or x-ray results for a patient within the past three years doesn’t, in itself, make that patient an “established” one.
If a physician sees a patient for the first time as part of “covering” for another physician, the patient’s “new” or “established” status will depend on whether the patient is established with the unavailable provider.
Or if an established patient who has been receiving services from providers in one specialty or subspecialty then sees a provider in a different specialty or subspecialty, the patient is still considered new to that second provider within the same practice. (As Dick cautions her readers, be aware not all payers allow this particular exception).
In all cases, you must be certain you have the appropriate documentation. Still, more of your patient visits may warrant the “new patient” code 99205 than you might realize.
Correlate Severity and Sickness with Complexity
Code 99205 also applies to “presenting problems… of moderate to high severity.” Was our knee patient’s pain severe? Did we document that severity? The answer to both questions is yes.
Did his visit require we use complex medical decision-making? Yes again—as evidenced by our consultation with his new physician, our review of his medication records, and the follow-up we pursued.
When the MDM in a patient visit is of high complexity, code 99205 is appropriate provided the physician can document both a comprehensive history and a comprehensive exam. Physicians who develop the habit of adhering to the MDCodePro standard of comprehensive histories and exams—“just as we learned in medical school,” says Dr. Alexander Stemer, MDCodePro’s founder—will have that documentation.
And remember: Only two of the three MDM elements (data points, diagnosis points, and patient risk) are required to be at the same level for any particular level of complexity. Physicians shouldn’t undervalue their MDM, which they often do without even realizing it because the more experienced they become, the more “second nature” MDM becomes.
But whether you’re a long-time practitioner or just getting started, MDM is a measure of the cognitive effort and expertise you bring to a patient’s condition, and you deserve to be reimbursed appropriately for it. If your MDM is at the highest level of complexity, then code 99205, indicating the highest level of care, is justified, when accompanied by a comprehensive history and a comprehensive exam.
Confidently Identify Level 5 New Patient Visits with MDCodePro
Have you ever hesitated to assign code 99205, or any of the highest level CPT® codes, to a patient visit, even when you know such coding would be entirely appropriate?
We understand. After all, news stories about doctors who exclusively bill at the highest level leave a bad taste in responsible healthcare professionals’ mouths.
Or maybe you worry too many high-code visits will flag you for audit. However, frequent undercoding will deprive you of tens of thousands of dollars annually. And don’t forget deliberate undercoding is as much a falsehood as deliberate overcoding. Not only does deliberate undercoding count as “misusing codes on a claim” (the CMS definition of “abuse”), it also fundamentally misrepresents the facts about a patient visit (the CMS definition of “fraud”), as the AAPC’s John Verhovshek warns readers. It’s a failure to comply that simply isn’t worth the risk.
By following MDCodePro best practices and scoring visits using our reliable, audit-validated Code Generator, you can use CPT® code 99205 and other high level codes with peace of mind whenever they are justified, because you know your documentation will support your decision.