tci E/M Coding Alert - 2013 Issue 1

You Be the Coder: New Patient Vitals Won't Make the 99203 Grade

Question: A new patient presented in our office. Past medical, social, and family history were obtained. The provider documented a comprehensive HPI and a complete (10) ROS. The diagnosis was moderately complex and there was data management. However, no physical exam was done other than vitals being taken. The provider did not document face-to-face time spent with patient. Can I bill more than a 99202? Supercoder.com Ask an Expert Customer Answer: For a new patient, the level designation is determined by all three of the key elements: history, examination, and medical decision making (MDM). Therefore, even if you...

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