Question: How should I report the following case for an established patient?
- More than 10 minutes discussing importance of quitting smoking
- Comprehensive history, comprehensive exam, moderate MDM
- ECG and interpretation
- Occasional palpitations, benign HTN, tobacco use, atypical chest pain, COPD.
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Answer: Your case involves tobacco cessation counseling, an established patient office visit, and electrocardiogram (ECG) for a patient with multiple diagnoses. Assuming there’s proper documentation, you may report the ECG and tobacco cessation counseling in addition to the E/M service.
Smoking cessation: The physician documents more than 10 minutes of counseling, so you should report 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes). Be sure the session meets payer frequency requirements. Also, remember Medicare has distinct codes if the patient is asymptomatic for tobacco-related disease (G0436-G0437, Smoking and tobacco cessation counseling visit for the asymptomatic patient …). This patient has COPD so the G codes would not apply.
E/M: For this established patient visit, you need to meet two of the three component levels for history, exam, and medical decision making (MDM). The noted levels seem to support 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …).
However, the E/M service must be distinct from...
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