In my experience the first face to face encounter is when you bill the 'new' visit
The difference between 'new' and 'established' patients is as you said based on the F/F date
Presuming you are meeting the idea that no other F/F has been performed by your MFM or the MFM group in the past 3 years, I am not sure why the 99204 would be denied. I would ensure you submitted appropriate modifier that it was a separate distinct service that day separate from the 76816 (which I assume was done to follow-up images not obtained on the detailed, or to review something that was abnormal?). Or the payer may be questioning the need for the 76816 - so then I would make sure the appropriate indications for performing the 76816 are noted.
If you would like the committee to weigh in on this response and/or submit more information in regards to the denial you received from the payer please submit this question on the SMFM website which is confidential so that patient information is not disclosed.
thanks
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Vanita Jain, MD
Chair, SMFM Coding Committee
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Original Message:
Sent: 02-22-2021 13:52
From: Aldo Khoury
Subject: New Patient E&M Question
Hello,
I recently received a denial on a new patient E&M CPT code because new patient qualifications were not met and I'm interested to see if anyone can provide their experience/insight on this. We saw a new patient for an anatomy scan that resulted in abnormal findings. Our MFM was out of the office that day so the sonographer did not discuss these findings with the patient and scheduled a follow up visit with the MFM a week later. We billed a 76811 with no E&M code and when the patient returned a week later she had a face to face encounter with our MFM so we billed the 99204 with 76816.
Were we incorrect to bill a new patient encounter since the patient had a prior ultrasound with us or should we appeal this as it was the first face to face encounter? Thanks for your help.
Lynn Halsey on behalf of Dr Khoury
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Aldo Khoury
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