Your New Patient Exam Code Could Determine How Many Visits You Get

The initial exam is where the provider gathers the information to determine the need for all the care that follows. It is billed most often as an office or outpatient evaluation and management (E/M) code from the 4th edition of the AMA’s Current Procedural Terminology book. There are actually five new patient codes to choose from, ranging from 99201 (the least intense and hence, least profitable) to 99205 (most intense and most profitable). Though subject to change in the next few years, these codes are currently assigned based on three key components; History, Exam, and Medical Decision Making.

Some providers have mistakenly thought that, as long as you can document a significant amount of the requirements contained in these three key components, you can bill as high a code as you like. However, the volume of documentation is trumped by something known as medical necessity. In other words, a really great exam has to have a really good reason behind it.

When I worked as an associate many years ago I sat in on a meeting where our biller informed us that several of our 99204 new patient exams had been sent to the fraud unit of a major insurance carrier for investigation. The clinic owner became upset with the biller and told her that it was her job to get us paid and that we did great exams. She explained that the payer claimed that our exams were not medically necessary. But the clinic owner refused to learn the rules of E/M coding and would not accept her explanation. The moral of the story: no matter how much you document, your patient must have a problem that justifies the evaluation.

In addition to three key components, the E/M guidelines describe five types of presenting problems. They are defined as follows (emphasis added):

Minimal: A problem that may not require the presence of the physician or other qualified healthcare professional, but service is provided under the physician’s or other qualified health care professional’s supervision. Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance. Low severity: A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected. Moderate severity: A problem where without treatment the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment. High severity: A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment. — CPT 2019 by the AMA

The underlined portions represent words that are more consistent with conditions treated in a chiropractic setting. If the provider documentation were to use these words, an auditor would be able to easily identify the nature of the presenting problem.

For the new patient E/M office/outpatient codes, the nature of the presenting problems, per the guidelines, are usually:

99201 - “self-limited or minor”

99202 - “low to moderate severity”

99203 - “moderate severity“

99204 and 99205 - “moderate to high severity”

For established patients they are as follows:

99211 - “minimal”

99212 - “self-limited or minor”

99213 - “low to moderate severity”

99214 and 99215 - “moderate to high severity”

Before beginning an exam, the clinician might consider the nature of the presenting problem, use that to decide what level of exam is appropriate, then make sure to document appropriately. A chiropractic case that requires 20 or more visits might be more likely to correlate with more severe presenting problems. A 99203 could therefore be expected to precede these types of cases. A 99202 might precede a case that only requires ten or fewer visits.

I suggest that your notes indicate wording that support the type of presenting problem that correlates. For example, “probability of prolonged functional impairment”; is consistent with a moderate presenting problem and that is consistent with a 99203 or 99214. If your assessment says, “full recovery without functional impairment is expected”, then I would expect a 99202 would be billed for a new patient, or a 99213 for an established patient.  

The underlined verbiage in the five types of presenting problems, in my opinion, is most fitting for musculoskeletal conditions. The wording can just be added somewhere in the assessment portion of the note. It does not have to be listed next to the code.  Keep in mind that the three key components still need to be satisfied, but, with medical necessity determined, they should follow without any trouble.

Dr. Evan Gwilliam is the Clinical Director for PayDC, a chiropractic EHR software that was designed with compliance in mind. He can be reached at evan.gwilliam@paydc.com if you would like to request a software demo.

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