I attended a recent ASPS coding course and heard you speak – you were terrific! i didn’t realize how important E&M coding was and more importantly the documentation for it. When consider level 4 and 5 new patient or outpatient consults, I see that a comprehensive physical exam is needed. Should I be using the 1995 or 1997 guidelines?
Thank you so much – I love what I do and I hope it shows when I teach. Yes, E&M coding and documentation is very important. You’ve asked a good question and one that is not easily answered by me – only you can decide which exam guidelines to use based on the examination you perform.
A comprehensive examination is required for a level for level 4 and 5 new patient visits (99204, 99205) and outpatient consultations (99244, 99245). So what is a comprehensive exam?
Medicare’s 1995 guidelines are organ system-oriented; a comprehensive exam requires assessment and documentation of at least 8 of the following 12 organ systems:
- Constitutional (e.g., vital signs, general appearance)
- Ears, nose, mouth and throat
- Hematologic/ lymphatic/immunologic
Medicare’s 1997 guidelines are organ system-specific, meaning each organ system includes specified examination elements (also known as “bullets” or “elements”). The following organ systems have a specified exam:
- Ears, Nose, Mouth and Throat
- Genitourinary (Female)
- Genitourinary (Male)
- Hematologic/ Lymphatic/Immunologic
Alternatively, Medicare’s 1997 guidelines allow for a general multi-system exam. You’ll need to review each organ system’s 1997 exam elements as well as the general multi-system exam elements to determine if this works best for you.
I recommend you look at the CMS website for more detailed information about the examination guidelines.
Most plastic surgeons find that it is difficult to report level 4 and 5 consultation (9924x)/new patient codes (9920x) due to the comprehensive examination requirements. However, oftentimes these high level codes can be reported based on your face-to-face time spent counseling the patient in the office setting.
I’d be happy to review a couple of your E&M notes and work with you to determine which exam guidelines are to your benefit and whether your documentation meets the criteria for level 4 and 5 codes. Please contact Natalie Loops at KZA for more information about KZA’s professional fees (312.642.5616 or email@example.com).