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Explore This IssueFebruary 2013
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Answer: 99214 (not incident-to)
Diagnosis: 715.96, 528.02, E943.8
This was an established patient visit with an established diagnosis along with a new diagnosis. The visit should be coded as 99214 and billed under the PA’s national provider identification (NPI) number.
History: Detailed history
- History of present illness contained six elements: location, duration, timing, severity, context, and modifying factors
- Review of symptoms contained two elements: musculoskeletal and gastric
- Past family, social history: The past medical history was taken
Examination: Detailed examination
- Five systems were examined: constitutional, cardiovascular, gastric, musculoskeletal, and respiratory
Medical decision making: Moderate
- One stable problem improving and one new problem without workup: extended
- No data review or ordered: minimal
- Prescription drug management: moderate
This visit must be billed under the PA’s NPI number to receive 85% reimbursement of the approved Medicare Part B Physician Fee Schedule. This visit cannot be billed as incident-to because the PA treated an established patient with a new diagnosis. If the patient had not presented with a new problem—queasiness—then the visit would be considered incident-to.
One of two choices can be made when an established patient presents with a new problem—the PA/NP can continue the visit without any physician input and receive the lesser reimbursement (85%) or the physician can restart the visit from the history of present illness and receive the full reimbursement (100%).