Outpatients Coding

The E/M section is organized into broad categories:

Office visits

New patient
Established patient.

Hospital inpatient or observation care visits

Initial Hospital/observation care
Subsequent Hospital/observation care
Discharge

Consultations

Outpatient consultation: - 99242 to 99245
Inpatient consultation: - 99252 to 99255

Office Visit

The following codes are used to report evaluation and management services provided in the office or in an outpatient or other ambulatory facility. A patient is considered an outpatient until inpatient admission to a health care facility occurs.

Determine the patient status as New or established: -

New Patient: A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Established Patient: An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Office Notes:

Office notes are of 2 types:

Office notes for new patients: A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Here in these notes, Patient is coming first time to the office or 3 years and is coded with new patient and the codes given below table. In this we find detailed documentation of History (HPI, ROS, PFSH), Exam, and MDM. Still the level is decided based on the MDM alone. But physician needs to document the pertinent History and Exam

New Patient note example:

Established Patient note:

Patient: Mr. Z

Age: 55

Presenting Complaint: Poorly controlled diabetes

History of Present Illness (HPI):

55 years of Mr. Z return to the office and has a history of type 2 diabetes mellitus. Despite medication, his blood glucose levels have been consistently high.

Review of Systems (ROS):

- Endocrine: As per HPI.

- Cardiovascular: No chest pain or palpitations.

- Gastrointestinal: No nausea, vomiting, or abdominal pain.

Past Medical History (PMH):

- Type 2 Diabetes Mellitus

- Hypertension

Physical Examination:

- General: Alert, oriented, in no apparent distress.

- Cardiovascular: Regular rate and rhythm. No murmurs.

Assessment:

The patient's diabetes is poorly controlled.

Plan:

- Adjust medication regimen (add Glipizide 5mg daily to current Metformin therapy)

- Recommend meeting with a dietitian

- Follow-up appointment in one week to assess response to treatment.

EM Navigation

Office notes for established patient

Established Patient: An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

In this type of encounter, the patient returns to his PCP or his doctor within 3 years, here it only requires to document the pertinent History and Exam. Level is decide based on the MDM alone.