Cardiology Coding Alert

Question: We’ve been getting a denial for new patient code 99204. The only service the physician provided to the patient in the last three years was a 93306-26 in the hospital without ever seeing the patient. Should we be using an established patient code?

Codify Subscriber

Answer: A new patient code is correct when the only previous service provided was 93306-26 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography; Professional component). 

You should look into whether any other physician from your group has provided the patient with a face-to-face service in the past three years, though.

Here’s why: E/M guidelines define a new patient as one who hasn’t received a face-to-face service from the physician or a physician of the same subspecialty in the past three years.

Medicare Claims Processing Manual, Chapter 12, Section 30.6.7, offers a similar rule, although it refers to the specialty (instead of subspecialty) level: “Interpret the phrase ‘new patient’ to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient” (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf).

Sharing this quote and CPT®’s new patient definition with the payer may help with an appeal for 99204 (Office or other outpatient visit for the evaluation and management of a new patient …) if the payer follows Medicare rules or does not provide its own specific guidance on use of new patient codes. Third party payer rules on the definition of new and established can vary.