Coding & Documentation

Yes, the order does matter. The physician should list on the encounter form the diagnosis (ICD-9) code that is associated with the main reason for the visit. This is the primary diagnosis, and in most cases it should be listed first on the claim form, followed by codes that describe any coexisting conditions that affect patient care, treatment or management. Each diagnosis code should be linked to the service (CPT) code to which it relates; this helps to establish medical necessity. Any changes to codes or to the order in which they are listed on the claim should be approved by the physician. In some cases, the ICD-9 guidelines may require that certain codes be reordered. For example, the physician may list an ulcer of the ankle first, followed by a related condition such as diabetes. However, because ICD-9 instructs to “Code, if applicable, any causal condition first,” the code for diabetes with other specified manifestations, 250.8X, might need to be listed first, followed by 707.13 for the ulcer.

The Documentation Guidelines for Evaluation and Management Services addresses this by indicating that if the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history. You should document why the ROS was not possible and obtain a history of the present illness and a past, family and social history from the family, caregiver or past medical records as appropriate.

No. Insurance status is not a factor in the CPT definition of a new patient, which is the definition that most payers use. According to CPT, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” To learn more about new versus established patients, see “Understanding When to Use the New Patient E/M Codes,” FPM, September 2003.

No. Though usually provided in an emergency department or other hospital setting, critical care services are not limited by site of service. However, both the illness or injury and the treatment delivered must meet the requirements defined in CPT. The introductory text to codes 99291 and 99292 in the CPT manual includes information you may find helpful. Note that a critical care service of less than 30 minutes total duration should be reported with another appropriate evaluation and management (E/M) code.