“A new patient was seen with heel pain. X-rays were taken at an outside facility, and I independently interpreted these and reviewed the labs. Based on medical decision making, I believe I should be coding CPT 99204. The patient had one new, acute problem (previously undiagnosed) and I independently interpreted tests. To me this is a no brainer, but my office staff argues that they believe it should be CPT 99203. Thoughts?"
So, a new patient was seen with heel pain. X-rays were obtained at an outside facility. The physician, seeing this patient for the first time interpreted the X-rays and I am assuming that the physician generated a written report. I am sure that a medically appropriate history and/or a medically appropriate examination were performed and documented. The physician is assuming that based upon medical decision making that E/M code 99204 would be appropriate to bill for this encounter. Let’s talk about this.
The Level of Medical Decision-Making Table is to be used as a guide to assist in selecting the level of Medical Decision Making for reporting an E/M service code. The table includes the four levels of Medical Decision Making (ie, straightforward, low, moderate, high) and the three elements of medical decision making (ie, number and complexity of problems addressed, amount and/or complexity of data reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management). To qualify for a particular level of medical decision making, two of the three elements for that level of medical decision making must be met or exceeded.
In the posted scenario, since radiographs were obtained at an outside source and the radiographs were subsequently interpreted and reported by the treating physician, this certainly qualifies as a Moderate Amount and/or Complexity of Data to be Reviewed and Analyzed. This is classified as an Independent Interpretation of Tests, specifically “Independent interpretation of test performed by another physician/other qualified health care professional (not separately reported).” In addition, the physician identified “one, new, acute problem (previously undiagnosed).” In order to bill CPT 99204, the new problem would need to be identified as “1 undiagnosed new problem with uncertain prognosis.” This is defined as the following: “A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.” Clearly, plantar fasciitis does not fit into this description. Therefore, the Number and Complexity of Problems Addressed is not classified as Moderate. Thus, CPT 99204 cannot be billed.
So, what should be billed? Under Number and Complexity of Problems Addressed, the most appropriate problem is “1 acute, uncomplicated illness or injury.” This is defined as the following: “A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.” Plantar fasciitis would certainly fit into this description. As far as Risk of Complications and/or Morbidity or Mortality of Patient Management, the treatment of plantar fasciitis on the initial encounter, whether it is a prescription for an oral anti-inflammatory medication, a cortisone injection, or a referral to physical therapy would qualify for a “Low Risk of morbidity from additional diagnostic testing or treatment.” This would support the billing of CPT 99203 on the initial encounter for this patient.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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