Medicare Compliance & Reimbursement - 2020 Issue 12
Reader Questions: Beware of Assigning E/M in This New Patient Encounter
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Article Overview
This reader Q&A addresses coding considerations for a new pediatric patient encounter when the visit is for establishing care rather than evaluation of a problem. It helps pediatric, family medicine, and coding staff understand the general distinction between new patient E/M services and preventive medicine services, and why payer-supported medical necessity matters. The discussion is aimed at coders and practice staff who need to determine whether a visit should be billed, not billed, or considered under a preventive care framework.
Why This Topic Matters
Accurately distinguishing between a problem-oriented new patient visit and a preventive visit affects claim submission, compliance, and whether the encounter should be billed at all.
What You Will Learn
- How establish-care encounters may differ from billable evaluation and management services
- When a preventive medicine visit may be considered instead of a new patient E/M visit
- Why medical necessity and visit purpose matter for billing decisions
- What broad factors are referenced for pediatric preventive care encounters
Who Should Read This
- Medical coders
- Billing staff
- Pediatric practice managers
- Physicians and advanced practice providers
- Compliance staff
Codes Discussed
Code Ranges Discussed
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