HELP!! Consult/New Patient question...

I am having a problem, can anyone help??

I am auditing consults/NP notes and I have a doc that states....
PHYSICAL EXAM: Deferred

Everything else is complete but because the exam is part of the 3 out of 3- I can only code this as a 99241----RIGHT??? There isn't anything written except deferred, not the docs fault but still needed for the 3 out of 3.

Is there a way to code this at a higher level or am I doing this correctly???

Thanks!!!

Help!! Consult/New Patient question

You are correct.

Without vitals, it can't be billed at all--no exam means no new patient/consult.

If it met the criteria to be based on time, you could use time but I assume it didn't or you would have mentioned it.

Help

Thank you for your help- I work for a Hematology-Oncology office, so they should be doing SOMETHING!! LOL No there was no time mentioned but also, there wasn't any vitals mentioned either, so, from your response, does this mean it can't be coded at all as a consult? How would I code it then? I didn't realize that the vitals atleast had to be documented, but then again, this is the first time I have come across this too!!

Thanks again for all the help!!

No Vitals ok with time based billing

The Editor's answer was a little ambiguous.

The physical does require vitals to be billed, but time-based billing does not require them. And since this is a coding forum I will not comment on lack of exam except to say many oncologists have found abnormal lymph nodes and other signs of cancer that I have missed.

What specialty are you that the doc doesn't touch the patient?

Did the doc document time spent in counseling and coordination? If >50% time spent in counseling and coordination the doc can choose a code by total time spent. Time is 15, 30, 40, 60 and 80 minutes.

HELP!! Consult/New Patient question

I've just posted this article on the site: (it takes a few minutes to go through copyright protection/and update in the system, so I'm copying it here. It will be searchable soon.)

Does an E/M service require an exam? It depends on the category of service.

Established patients and subsequent hospital visits require two out of three of the key components, history, exam and medical decision making. Any two components at the level of documentation required determines the level of service. The exam does not need to be one of them. Many established patient visits meet the criteria in history and medical decision making.

Other categories of service, for example, new patients, consults and initial hospital services, require three of the three components to be at or exceed the level of documentation required. This means, in effect, that the lowest component selects the code. A new patient that has no exam is not reportable unless it meets the criteria for an E/M service based on time. (There is an article in Codapedia about using time to select a code.) An exam that includes vital signs or general appearance allows the service to be billed at the lowest level.

What should a practice do if there is no exam, and time is not a determining factor in selecting the code? Use the unlisted E/M code, 99499.

The CPT book defines the level of history, exam and MDM for each level of E/M code, and whether it requires two of three, or all three components. The Documentation Guidelines describe what makes up each level of history, exam and MDM.

E&m

I would agree, that you can not bill for this visit without some type of an exam conponent. It is appropriate to ask the provider to provide an addendum stating that he left out this conponent and complete some sort of an exam to allow this visit to be billed. He must state the date and time of the addendum and make a comment that this is an addendum to the initial visit.