The following scenario comes across our schedules/lists from time to time and is often reported with an Evaluation and Management (E/M) code (99202-99215) based on time.
Example: 44 year old male here for completion of paperwork, scanned copy into chart. ROS: None recorded. Exam: None recorded. A/P: Completion of paperwork and total face-to-face patient time 15 minutes.
When a patient presents without complaints, the visit likely does not meet the definition of a medically necessary encounter. Regardless of time spent, these visits DO NOT support codes 99202-99215. Third party payers, employers and Work Comp carriers may consider reimbursement if this is a request made by them. They may have unique reporting requirements in order to receive reimbursement for their request.
We also see visits documented “to establish care.” This is not a supported reason for reporting E/M codes. If a patient is establishing care for problems that are being addressed today, then documentation should describe the problems the patient presents with. In this circumstance, those problems being addressed should be reported as the chief complaint. Subjective details about presenting problems, paired with a medically appropriate exam and a clear clinical impression of the current status of these problems must be documented.
Quality documentation paints a clear picture of how sick the patient is today and how complex the amount of work is needed by the clinician while providing medical decision making details that support evaluation and management codes.