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Posted By Mary Peabody on 03-09-2020, 16:38:25 in Ob-Gyn
Hello Melanie,

If physical examination is not performed and documented for a new patient outpatient visit and counseling time is not documented, can the coder default to the established patient CPT code based on History and Medical Decision Makin? I know for inpatient, if the key components are not met for initial CPT 992221, the coder can code a subsequent CPT code
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Posted By Melanie Witt on 03-10-2020, 13:46:30
No you may not. This would have to be an unlisted E/M service. I would go back to the provider and ask them to add an addendum to the note that would incorporate the time spent with the patient. And depending on the reason for the visit, you might be using the 99401-99404 codes instead of a problem E/M service. There is a big difference between coding for a brand new patient and coding for an initial or subsequent visit for an established patient.
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