Coding

Expand all | Collapse all

New Patient E&M Question

  • 1.  New Patient E&M Question

    Posted 5 days ago
    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

    ------------------------------
    Aldo Khoury
    ------------------------------


  • 2.  RE: New Patient E&M Question

    Posted 4 days ago
    Hi Aldo,
    Doing an ultrasound study does not trigger the switch to making this patient an established patient. You can still do and bill for a consult a week later and it should count as a new patient if you have not seen that patient for an E/M visit in the past 3 years. However, I am unsure the 76816 done a week later is reimbursable unless you have an indication for a repeat ultrasound.

    ------------------------------
    Fadi Bsat, MD
    Past Chair, SMFM Coding Committee
    ------------------------------



  • 3.  RE: New Patient E&M Question

    Posted 4 days ago
    Hi Fadi,
    Thank you so much for your response - I will appeal the denial. The 76816 was necessary to complete the ultrasound so that paid with no issue.

    ------------------------------
    Aldo Khoury
    ------------------------------



  • 4.  RE: New Patient E&M Question

    Posted 4 days ago
    Hi Fadi,
    Thank you so much for your response - I will appeal the denial. The 76816 was necessary to complete the ultrasound so that paid with no issue.

    ------------------------------
    Aldo Khoury
    ------------------------------



  • 5.  RE: New Patient E&M Question

    Posted 4 days ago
    Hi Aldo,
    Before appealing the 99204 charge, you may want to re-submit it with the -25 modifier as Dr. Jain had suggested, to indicate it was distinct from the ultrasound 76816 also done that day.
    Fadi

    ------------------------------
    Fadi Bsat, MD
    Past Chair, SMFM Coding Committee
    ------------------------------



  • 6.  RE: New Patient E&M Question

    Posted 4 days ago
    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


    ------------------------------
    Vanita Jain, MD
    Chair, SMFM Coding Committee
    ------------------------------



  • 7.  RE: New Patient E&M Question

    Posted 3 days ago
    That seems odd to me as well. I would not expect reading an ultrasound to equate to an E&M. So unless that patient had an E&M from you in the last 3 years, I would think they should consider it a new patient (or possibly a consult if a consult was requested from a referring provider since the 3-year rule doesn’t apply to the consult CPTs, although many payers cross-walk those to non-consult E&Ms).