tci General Surgery Coding Alert - 2004 Issue 7

Reader Question: Patient's Status Drives Component E/M Coding

Question: During an office visit, our surgeon performed an expanded problem-focused history, a problem-focused examination, and low-complexity medical decision-making. Which level of E/M service should I report? Does the patient's status, new or established, affect the level?Washington Subscriber Answer: The patient's status does change the office-visit level. That's because you must meet the requirements for two of the three components for established patient visits, but new patient services mandate that you meet all three components. Report a level-three office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient ...) if the...

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