E/M for Worsening Chronic Condition

Question:

I have a patient with end stage renal disease who I saw yesterday in follow-up in the clinic. His ESRD is not at treatment goal, I recommended a fistula procedure and discussed specific risks and benefits of the procedure with the patient. What E/M level should I bill?

Answer:

ESRD is a chronic condition. If the patient is not at treatment goal as you stated, the complexity of the problem addressed is moderate. When recommending a major procedure if you discuss patient and procedure risks in detail and document this information in the note, the risk of mortality and/or morbidity of patient management is high. Based on these factors, the level of service would be moderate. Two elements must be met from the Medical Decision Making table for the level of service. Since this is an established patient, I would report 99214 (established patient office or other outpatient).

*This response is based on the best information available as of 6/05/25.

First Patient Encounter

Question:

I saw a new patient in the outpatient clinic several weeks ago. Now, the patient has been admitted to the hospital. The admitting physician has asked me to see the patient again for that same condition. This is my first time seeing them in the hospital for an inpatient visit. What EM code do I bill for this visit?

Answer:

The E/M code for an initial inpatient visit, regardless of whether the patient was new or established to you, would be billed with either an inpatient consultation code (99252-99255) or an initial hospital code (99221, 99222, 99223 ) with the appropriate level based on MDM or Time.

*This response is based on the best information available as of 5/22/25.

E/M Level When Patient is Non-compliant With Treatment Advice

Question:

An established patient presents to my office with severe exacerbation of an existing condition, and I recommend they be urgently transferred to the ER for admission. The patient refuses and prefers to leave against my medical advice. May I still bill a level 5 E/M for a high level problem that requires hospitalization and urgent intervention?

Answer:

Yes. If a visit MDM would equate to a level 5 visit (e.g. 99215) based on the presenting problem (severe exacerbation) and risk (urgent admission with intervention), patient non-compliance with a provider’s medical recommendations does not preclude the provider from billing the appropriate level E/M.

*This response is based on the best information available as of 5/8/25.

Consultation Request by Another Specialty

Question:

Cardiology performs a procedure on an inpatient, and later in the day, the patient develops a pseudoaneurysm. When vascular is called in to evaluate the patient, can vascular bill for the evaluation?

Answer:

Yes, vascular can bill for an appropriate level E/M inpatient or consultation. The cardiologist is requesting the skill of a vascular surgeon to evaluate a vascular condition that is separate from the preceding cardiology procedure (i.e., complication).

*This response is based on the best information available as of 4/24/25.

Iliac Angioplasty and Stent Coding: Per Vessel or Per Lesion?

Question:

The surgeon documented angioplasty and stents for occlusive disease in the right common and external iliac arteries. Is this reported with one or two codes?

Answer:

That depends! Coding is reported per lesion, not per vessel. So, if a single lesion extends across the two iliac vessels, external and common, only one code is reported, 37221. However, if two separate and distinct lesions are in these two vessels, separately treated with angioplasty and stents, then two codes may be reported, 37221 and +37223. Documentation of two separate and distinct lesions will be key!

*This response is based on the best information available as of 4/10/25.

Inpatient Consultation Coding for Medicare

Question:

If you see a Medicare patient for the first time in the hospital as an inpatient consultation, what code would you bill for the EM?

Answer:

The EM would be reported as an Initial hospital or observational care codes (99221-99223) with the appropriate level based on MDM or Time. Medicare does not allow payment for inpatient consultation codes 99252-99255.

*This response is based on the best information available as of 3/27/25.