Established Patient New Problem

Established Patient New Problem

June 11, 2020

Question:
I saw an established patient for her last lumbar epidural in the series and she now complains of right upper extremity radiculopathy. I spent over 30 minutes with her discussing this with her before the performing the epidural injection. I can bill for a visit, right?

Answer:

Yes, as long as the discussion was regarding the new upper extremity pain and the visit is supported with documentation, then you can bill for a separately identifiable E/M (visit). If the service was performed in the office or the outpatient department of the hospital, you would choose a code from the 99212-99215 series (with modifier -25) on the visit code.

If over 50% of your visit was spent in counseling and/or coordination of care for the new issue (not on the existing issue), then you can use time-based service billing. Of course you would not want to use time-based billing on a routine basis, but it is available.

*This response is based on the best information available as of 06/11/20.

 

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