Oral Appliance Evaluation – E&M Coding

[niermanpm]

Hi Eastland Dental Center! Great questions. Yes 99242 can be used when a patient is directly referred from another healthcare professional. Using this group of Evaluation & Management (E&M) codes, known as “consultation” E&M codes, 99241-99245 does require the direct referral as well as a letter back to the referring health professional. However, Medicare stopped accepting these codes back in 2010, so some private insurers no longer accept them either. In general, the “consultation” E&M coding set 99241-99245 does have a bit higher allowed amounts than the “new patient” E&M coding set 99201-99205. When it comes to the documentation requirements vs. time spent for E&M coding, most practices go by documentation requirements, which for each level of code (1-5) requires a certain level of history taken from the patient, a certain level of exam performed by the doctor, and a certain level of medical decision making. If you are using time spent as the key factor for selecting the level of E&M code, yes you always want to make sure that you record the amount of time the patient spent face to face between the patient & doctor, and that at least 50% of that time was spent counseling the patient (and also important to note what was discussed during the time spent counseling). Here is the break-down of the required documentation for the different levels & types of visits: New Patient Codes (not referred) 99201 • 10 min face to face w/ doc – Presenting problems are self-limited or minor Or • A problem focused history • A problem focused exam • Straightforward medical decision making 99202 • 20 min face to face w/ doc – Presenting problems are low to moderate severity Or • An expanded problem focused history • An expanded problem focused exam • Straight forward medical decision making 99203 • 30 min face to face w/ doc – Presenting problems are moderate severity Or • A detailed history • A detailed exam • Low complexity medical decision making 99204 • 45 min face to face w/ doc – Presenting problems are moderate to high severity Or • A comprehensive history • A comprehensive exam • Moderate complexity medical decision making 99205 • 60 min face to face w/ doc 0 Presenting problems are moderate to high severity Or • A comprehensive history • A comprehensive exam • High complexity medical decision making Established Patient Codes: 99211 • Visit may not require presence of doc, typically 5 min spent with patient Or • Do your SOAP notes! 99212 • 10 min face to face w/ doc – Presenting problems are self-limited to minor Or • A problem focused history • A problem focused exam • Straightforward medical decision making 99213 • 15 min face to face w/ doc – Presenting problems are low to moderate severity Or • An expanded problem focused history • An expanded problem focused exam • Low complexity medical decision making 99214 • 25 min face to face w/ doc – Presenting problems are moderate to high severity Or • A detailed history • A detailed exam • Moderate complexity medical decision making 99215 • 40 min face to face w/ doc – Presenting problems are moderate to high severity Or • A comprehensive history • A comprehensive exam • High complexity medical decision making Consultation Codes (patient’s referred directly from other health providers) Special note on this set of E&M codes: • requires follow up letter to referring health professional • some companies no longer accept these codes, only new & established codes 99241 • 15 min face to face w/ doc – Presenting problems are self-limited or minor. Or • A problem focused history • A problem focused exam • Straightforward medical decision making 99242 • 30 min face to face w/ doc – Presenting problems are low severity Or • An expanded problem focused history • An expanded problem focused exam • Straightforward medical decision making 99243 • 40 min face to face w/ doc – Presenting problems are moderate severity Or • A detailed history • A detailed exam • Low complexity medical decision making 99244 • 60 min face to face w/ doc – Presenting problems are moderate to high severity Or • A comprehensive history • A comprehensive exam • Moderate complexity medical decision making 99245 • 80 min face to face w/ doc – Presenting problems are moderate to high severity Or • A comprehensive history • A comprehensive exam • High complexity medical decision making To learn more about E&M coding in medical billing, watch our recorded Tuesday evening study group over E&M coding! You can follow the link below, or visit the DentalWriter Help Center to watch the recording at any time! Hope this helps, have a great day!

[Jeremy Hobbs]

Consult Code vs New Pt

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