When we are calculating evaluation of management codes for a new patient, we will bill to the highest level of all three levels of history, physical, and medical decision making. And if she is an established patient, we'll bill to the highest level met by two out of three of those categories. Selecting the proper visit code depending on the nature or the problem of the patient comes with and what services are performed.
Determining an Established Patient
So for those new patients, these are services that are face to face services that were submitted for reimbursement. So if the patient has maintained a relationship with your office by way of telephone calls requesting prescription renewals, advice over the phone, those are non-billable, non-face to face services. So that would not maintain her as an established patient within the practice.
However, if she's come in for blood work and you’ve billed her for that blood work or performing that vena puncture or if you have provided services like a pregnancy test or a TB test or anything that was billable within the last three years, she will maintain herself as an established patient within the practice.
Key Components Of Evaluation And Management Codes
Evaluation of management codes has three key components. And those are history, physical exam and medical decision making. And you'll find them in the E/M section of the CPT code book. And those codes will start with 99 in the beginning of the code.
A basic understanding of evaluation of management coding is going to be needed to lay the foundation of how we can combine some of those complex encounters and bill for those appropriately.
So the key components for an evaluation and management code then are history, physical exam and medical decision making. Components of the history included chief complaint, a history of the present illness, review of systems and the patient’s past, family, and/or social history.
The chief complaint is required for all Evaluation and management visits. This is usually stated in patient’s own words as far as why the patient is presenting for care today.
So the reason for the encounter and if we don’t have a diagnosis, what her symptoms, conditions or complaints are. It is also acceptable for a chief complaint in the event of a preventive medicine visit to say here for annual needs refill of oral contraceptives or whatever. The chief compliant does not need to be an illness focused chief complaint.
It is not acceptable however to document here for recheck because as an auditor, that would be very inconclusive as far as what exactly you were rechecking. So it's important to say here for a test of cure, for vaginitis or here for rechecks of a near infection, whatever it is that the patient is coming in for follow-up care for.
We all learned way back in the beginning of our training that the history of the present illness includes elements that are factors that describe the chief complaint with respect to Location, Quality, Severity, duration, Timing, Context, Modifying Factors, what makes it better, what makes it worse, and associated Signs and Symptoms.