# Outpatient E&M for new problem



## cvand1972 (Mar 6, 2012)

Hello All. I need help.

One of our Cardiologists is asked to 'Consult' on a patient in Observation Status at the hospital for a 'new problem'. The patient is an established patient. The Cardiologist did not admit the patient to Observation, he was just asked to see the patient.

Consults aren't covered. 
Can I bill this as a 'new patient' office or other outpatient visit (99201 thru 99205) because this is a 'new problem' or do I have to use the 'established codes' (99211 thru 99215)??


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## stewardl (Mar 6, 2012)

If the patient is established (per CPT guidelines- the 3 year rule), then you must report an established patient encounter for this patient, even if being evaluated for a new problem.


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## rthames052006 (Mar 6, 2012)

cvand1972 said:


> Hello All. I need help.
> 
> One of our Cardiologists is asked to 'Consult' on a patient in Observation Status at the hospital for a 'new problem'. The patient is an established patient. The Cardiologist did not admit the patient to Observation, he was just asked to see the patient.
> 
> ...



You state above that this is an estaiblished patient, if this patient has had a face to face service from this physician  or another physician of the exact same speciality and subspecialty who belongs to the same group pracatice within the past 3 years, the patient is considered established.

If not, then you can bill a new patient visit.  Just because it's a "new problem" doesn't make the patient new to the provider. That particular information you would be using in the Medical decison making for the visit, in the Number of Dx or TX options you'd select "new problem" ( to the examiner), depending on if your provider is doing any additional work up will decide if you take the 3 points or the 4 points.

Also... the info I recited above regarding new patient rules can be found in your CPT book, I use the professional edition ( info is on page 11) under Coding Tip

Good luck to you....


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## cvand1972 (Mar 6, 2012)

Thank You.  I thought so but one of our Doctors is telling me that another Doctor out there is billing these 'established' patients as new because it is a new problem.  
This other Doctor is telling my Doctor that it is allowed.  
I need back up because I know that it is not allowed and no one is taking my word.


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