Internal medicine providers often encounter a perplexing billing scenario: new patient visits specifically for “establish care” purposes. These visits, coded with 99203-99205, frequently occur when patients present with no acute complaints or active medical issues, leading to diagnoses such as Z00.00 (routine general medical examination) and Z71.2 (health counseling and surveillance). This raises a critical question: how should Evaluation and Management (E/M) codes be accurately applied and justified in these situations?
The foundation of billing a sick visit lies in addressing a discernible problem, which necessitates some form of medical intervention, such as lab review or active management. In cases where a new patient presents solely to establish care, without any reported health concerns, the justification for higher level E/M codes (99203-99205) becomes unclear. Determining the appropriate E/M level and selecting accurate diagnosis pointers are crucial for compliant and ethical billing practices.
Consider this example: A new patient schedules an appointment to establish care. During the visit, she explicitly denies any current medical conditions or medication use. She mentions upcoming routine appointments with a gynecologist for a Pap smear, an annual eye exam, and a dentist visit. Her last primary care physician visit was several years prior. While she expresses slight anxiety about being in a doctor’s office and reports intermittent headaches following a past head injury (for which she did not seek medical attention and doesn’t suspect concussion), she denies any other acute symptoms or health problems. Her family history includes diabetes (father) and thyroid issues/chemotherapy (grandmother). She leads a healthy lifestyle, exercising regularly and eating well.
In this scenario, the patient’s presentation is primarily for establishing a relationship with a primary care provider for future healthcare needs, rather than addressing an immediate medical issue. The challenge lies in appropriately Coding Visits To Establish Care when the presenting concern is essentially preventive or for relationship building, and how to align this with E/M coding guidelines that typically necessitate the evaluation and management of a medical problem. Understanding the nuances of coding visits to establish care is essential for accurate medical billing and ensuring fair reimbursement for providers while adhering to coding regulations.
