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Posts: 1
Reply with quote  #1 
Can an established patient visit be billed for a new patient in the office if you don't have enough documentation to bill a new office visit level?

Posts: 33
Reply with quote  #2 
I'd say your bigger issue is the fact the physician leaves money on the table by not documenting properly or enough to code a new patient when it's a new patient. 

Why would you want to then bill as only established rather than have guidelines in place to make sure proper documentation is being done to bill as new patient.

Stop and think about how little is required to get to 99202. The doctor isn't even giving enough documentation for a 99202?  That's a much bigger problem to me.

And if you have a new patient that you aren't billing as a new patient, you run the risk (in my opinion) of billing inappropriately, which is almost as bad as billing for services not rendered.

My personal thought--I'm not going to downgrade an office visit and bill for services inappropriately.  I'm going to say this is not billable at all and put this back to the physician.  Because the physician didn't document the bare minimum needed for a 99202, you don't get to bill anything.  That financial impact should make the physicians think twice about documentation.

To report 99202, you only need
  • An expanded problem focused history; 
  • An expanded problem focused examination;
  • Straightforward medical decision making
Or even, a 99201, which needs less than that:

  • A problem focused history;
  • A problem focused examination;
  • Straightforward medical decision making

If you have enough to bill a 99212, then you should have enough for a 99201. 

Reply with quote  #3 
The amount of documentation does not distinguish whether a patient is new or established.  Per CPT Guidelines "A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the last three years".

Once new vs. established patient has been ascertained using this guideline, the E/M level is chosen based on the documentation/medical necessity.
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