What if the E/M code doesn’t meet all three components for an initial hospital visit?
Answer:
If an 'inpatient admission' (CPT codes 99221, 99222, 99223 or 99291) is necessary with all required components performed and appropriately documented, then that level of service is appropriate for billing and payment.
If criteria for even a (CPT code 99221) 'inpatient admission' are not met but a service was necessary and all of the required components performed and appropriately documented meet criteria for a 'subsequent visit' (CPT codes 99231, 99232 or 99233), then that level of service is appropriate for billing and payment (even though the service is chronologically an 'admission').
As far as the family history/ROS, do we get credit for statements like 'non-contributory' or 'unremarkable'?
Answer:
You cannot make a blanket statement stating ‘ROS non-contributory,’ but listing a system and saying it is non-contributory would be acceptable.
Do we get credit for the statement 'all other systems negative'?
Answer:
Yes, that is acceptable.
What if the E/M service does not include an exam or in a different circumstance, does not include the family history?
Answer:
If a patient does not meet the requirements of a certain code, you would go to a lower code. CPT code 99499 would be used in rare circumstances where the visit does not reflect the lowest level of E/M service in an applicable CPT code family, but still evidences medical necessity.
Should we bill as an established patient visit if the patient is just coming to meet the doctor and the doctor obtains a family history, etc. (but does not an exam)?
Answer:
For an established patient that doesn’t see the physician, CPT code 99211 doesn't require the key components or physician presence. An exam and history would be expected when you bill for a new patient.
If we have a demented patient who cannot provide family history, is it still acceptable if we document that in the notes?
Answer:
Yes, that would be acceptable.