Billing for a New Medicare Patient Requiring Baseline Lab Work
For a new Medicare patient seen to establish care who requires baseline lab work, you should bill the visit using the appropriate Evaluation and Management (E/M) code (99201-99205) based on the complexity of the visit, and separately bill for any laboratory tests ordered using the appropriate CPT codes.
Evaluation and Management (E/M) Coding
- For new Medicare patients, use the appropriate new patient E/M codes (99201-99205) based on the complexity of the visit, documentation requirements, and time spent 1.
- The level of E/M service should reflect the complexity of medical decision-making, history, and examination performed during the visit, not just the need for laboratory tests 1.
- Medicare recognizes physicians, physician assistants, nurse practitioners, clinical nurse specialists, and other qualified healthcare professionals as providers who can bill for these services 1.
Laboratory Test Billing
- Laboratory tests should be billed separately from the E/M service using the appropriate CPT codes for each test ordered 1.
- When ordering baseline laboratory work during an initial visit, the tests are considered distinct services and should not be bundled into the E/M code 1.
- Document the medical necessity for each laboratory test ordered to support proper reimbursement 1.
Documentation Requirements
- Ensure your documentation supports the level of E/M service billed by including appropriate elements of history, examination, and medical decision-making 1.
- For a new patient visit, documentation should fulfill the need for continuity of care and demonstrate the complexity of the encounter 1.
- Include clear documentation of the rationale for ordering baseline laboratory tests as part of establishing care 1.
Common Pitfalls to Avoid
- Avoid "upcoding" by selecting a higher E/M level than supported by documentation, as nearly 26% of E/M claims for Medicare patients are incorrectly upcoded 1.
- Don't "downcode" out of fear of audit, as approximately 14.5% of E/M claims are incorrectly downcoded, potentially leading to lost revenue 1, 2.
- Don't include the laboratory tests as part of the E/M service; they should be billed separately 1.
Special Considerations
- If the patient requires additional follow-up specifically to review laboratory results, this may be billable as a separate encounter depending on the complexity and timing 3.
- For Medicare patients, be aware that certain preventive laboratory tests may be covered under Medicare's preventive benefits and should be coded accordingly 1.
- Remember that accurate coding is essential, as studies show family physicians are generally accurate in their billing procedures with concordance rates around 55% 2.
By following these guidelines, you can ensure appropriate reimbursement while providing quality care to your new Medicare patients requiring baseline laboratory work.