CPT 2001 Clarifies New vs. Established Patient
Published on Mon Jan 01, 2001
Cardiologists are often unable to determine if a patient they are seeing face-to-face for the first time should be classified (and coded) as a new or established patient. The problem potentially occurs when they are called on to read echos or electrocardiograms (ECGs) in the hospital. In many cases, the cardiologist may not know the patients name, because the test is identified by a bar code only.
Subsequently, the same patient may visit the cardiologist in his or her office. Until now, CPT guidelines stipulated the visit would have had to be billed as an established patient visit, because a test interpretation constituted a professional service. CPT defined a new patient as 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.
Payers reimburse at a higher rate for new patient visits (99201-99205) than for established patient visits (99211-99215) because of the more extensive nature of a patients initial visit. For example, a level-three new patient visit (99203) has been assigned a value of 2.19 relative value units (RVUs). The same level visit for an established patient (99213) reimburses 1.20 RVUs. This policy was considered unfair to cardiologists and other specialists who read test results at the hospital, says Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Dana Point, Calif.
Fletcher notes that had cardiologists followed CPT guidelines, established patient visits would have to be billed for patients they had never met before. Cardiologists who were unaware of the identity of the patients whose tests they interpreted may have billed a new visit through no fault of their own when one of those patients visited their office, she says.
For 2001, however, the introduction to the evaluation and management (E/M) section of CPT contains an important change, and now reads:
Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s).
The change in wording means that even if the cardiologist happens to be on staff at the hospital to read echos or ECGs, and the patient later visits the cardiologist in his or her office for followup for a cardiac condition, the patient should be considered new, because no face-to-face services were performed, Fletcher advises.
Change Aligns CPT With Other Carriers
The change may not affect billing for Medicare or private carriers who differed with the previous CPT on this issue. Fletcher notes that there is no national Medicare policy regarding test interpretations and new patient visits, meaning that individual Medicare carriers have to establish their [...]
