Physical Exam: 150/90 90 Tmax 98.9 (three vital signs = one bullet) alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam. (at least 2 bullets each in nine areas/systems)
As you know, documenting the status of three chronic medical conditions can substitute for the HPI. Add in at least 10 additional review of systems and one element each from past history, family and social elements and the minimum history documentation required for CPT® 99204 has been met. The physical exam meets the comprehensive requirement with at least two bullets in each of nine areas or systems. All physical exam components offer value to the encounter to exclude potential complications of therapy or to search for evidence of decompensated disease.
The MDM is moderate complexity. This progress note documentation gets four diagnosis points for discussing two stable problems (two points total for DM and COPD) with an established problem that is worsening and no more work up planned (two points for HTN). In addition, zero points are earned for the data component, but risk is moderate based on prescription drug management. Prescription drug management is considered moderate risk. This is displayed on my bedside E/M reference card shown below. The highest two out of three components for MDM are of moderate complexity and therefore this overall documentation supports CPT® 99204. Below is another example of a new patient 99204 office visit:
S: HA present 4/10, global pain for 3 days and constant. No ringing in the ears. (at least 4 HPI) No fever, no neck stiffness, no nausea/vomiting. No chest pain or SOB. All other systems reviewed and negative. (at least 10 ROS based on this notation) No history of migraines. Nonsmoker. No FH brain cancer. (one element each from past history, social and family elements)
O: 120/80 90 Tmax 98.9 (three vital signs = one bullet), no head trauma, alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam. (at least 2 bullets each in nine areas/systems)
A: Acute HA, NOS. Stable. (one new problem with more work up planned and of uncertain prognosis is 4 points on MDM for diagnosis and also moderate risk too)
P: Check CBC/BMP. Continue to observe.
This new patient outpatient evaluation is appropriate for CPT® 99204 as the history, physical and MDM all contain the necessary documentation based on the Marshfield Clinic audit tool. Medical decision making is moderate because the diagnosis element is high complexity (4 points for new diagnosis with more work-up planned), the data element is low complexity (only one point for ordering lab), and the risk table is moderate for dealing with an undiagnosed new problem with uncertain prognosis. Therefore, the highest two out of three elements in MDM are moderate. Here is another progress note example of a level 4 new patient office visit:
S: 48 year old male here to establish care. No CP/SOB/N/V/HA. No neuropathy. No polyuria or polydypsia. Average blood sugar reading 145. All other systems reviewed and negative. (at least 10 ROS based on this notation) Nonsmoker. No family history of CAD. Diabetes type II for 10 years. (one element each from past history, family and social elements)
O: 120/80 90 Tmax 98.9 (three vital signs = one bullet), no head trauma, alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam. (at least 2 bullets each in nine areas/systems)
A: 1) HTN, controlled. 2) DM II, uncontrolled. 3) CAD, controlled. (three points on MDM for diagnosis and substituting three chronic medical conditions for HPI)
P: Increase Metformin from daily to BID dosing. (moderate risk for prescription drug management)
Both the history and physical meet minimum criteria for CPT® 99204 with comprehensive requirements documented for both. Medical decision making is moderate based on a moderate risk table assessment and three points in the diagnosis section. No points are achieved in the data section of MDM, but none are necessary. Remember, the highest two out of three elements from data, diagnosis and risk determines the overall level of MDM complexity.
USING NEW PATIENT CLINIC CODES IN THE HOSPITAL SETTING
The CPT® medical billing code group 99201-99205 should
used by hospitalists and other physicians or
non-physician practitioners in the hospital setting under certain
circumstances. I have previously discussed all the possible initial encounter codes that
could be used in the hospital setting. These new patient
clinic and other outpatient visit codes are included as possibilities.
I have provided a detailed discussion of that decision tree analysis
at the link provided just above. However, I will discuss the pertinent
portions of that analysis here.
For patients admitted
observation status, the attending physician should choose from the
observation group of medical codes 99218-99220 for the initial
encounter, 99224-99226 for observation status follow-up codes, and 99217
for observation discharge. Under certain situations, same day admit
and discharge billing codes 99234-99236 or critical care procedure codes
may also apply too. This is not the case for consultants taking care
of observation status patients. What codes should a consultant use in
an observation status situation? This is where the correct code
decision can get very complicated. Medicare no longer recognizes
consult procedure codes. Consultants should pick the appropriate level
of service from the new outpatient clinic code group 99201-99205
as their initial encounter, but only IF the patient has NOT been seen
previously by the physician or a physician partner of theirs in the
same group and exact same specialty and subspecialty within the previous three years. Alternatively, critical care codes can be used instead if documentation supports their use.
If
the patient HAS been seen in the last three years by the same
physician or partner physician in the same group and exact same
specialty and subspecialty, the consultant should use the established patient
clinic code group 99211-99215 on their initial date of service and continue to use that code group for
all subsequent observation services, including the day of discharge.
Remember, all hospital observation CPT® code groups are reserved only
for the attending physician. If a patient qualifies as a new patient but clinician documentation does not support any code from the code group 99201-99205 (usually because of the three out of three documentation requirement), then it is appropriate to instead choose a code from the established patient code group (99211-99215) that meets documentation requirements. This guidance has previously been confirmed by Medicare carriers.
The above discussion
relates to Medicare because Medicare does not accept consult codes.
Other insurances may still accept consultation codes. In those cases,
the consultant should chose a level of service from medical code group
99241-99245 (outpatient consult codes) as the initial encounter and then
pick a billing code from the established patient clinic codes
99211-99215 for all subsequent care visits, including the day of
discharge, while the patient is hospitalized for observation services.
If the patient is formally admitted inpatient, the consultant should
use the inpatient subsequent care codes 99231-99233 for
all subsequent face-to-face encounters.
DISTRIBUTION OF NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT CODES (99201-99205)
What is the distribution of CPT® code 99204 relative to other levels of service in this medical code group? The chart below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services on page 21. As you can see, between 2001 and 2010, the distribution of new patient office visits 99204 and 99205 has shifted higher (an increase of 12% and 4% respectively) while the proportion of level three 99203 has remained constant with no change from 2001-2010. On an absolute basis, of all codes in the group 99201-99205, CPT® code 99204 represented 35% of all services from code group 99201-99205.