ED Coding and Reimbursement Alert

CPT 2007 manual includes tool for deciding on new, established patients

When an ED physician has cause to use new and established patient evaluation and management (E/M) codes, coders have to be ready to discern new patients from established ones. Proper coding for various E/M services (such as outpatient visits and rest home services) rests on determining whether a patient is -new- or -established,- as defined by AMA guidelines.

Do you use these codes? While the standard ED coder likely won't have to use the new (99201-99205) or established (99211-99215) patient codes, ED facilities and physicians that practice outside the traditional ED setting will need them. For example, ED groups that run clinics, urgent cares and hospitalist functions performing clinic follow-ups must use the new and established patient E/M codes.

Help's here: To make the new vs. established decision easier, CPT 2007 includes a flow chart on page 2: Now, a foolproof decision is only a few questions away. However, you should be careful when consulting the flow chart. Some of the language in the flow chart may confuse coders into filing legitimate new patient visits as lower-paying established patient E/Ms.
 
But don't fret: As long as you follow the proper path when reporting new and established patient E/Ms, you-ll get it right every time. Here's a quick refresher on how to tell new patients from established ones.

Be Sure to Apply -3-Year Rule-

If the physician (or any physicians of the same specialty billing under a common group number) has never seen a patient before, that patient is automatically -new.- In addition, if the same physician (or any physicians of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient -new- from a coding standpoint, confirms Suzan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician educator for the Department of Surgery at the University of Pittsburgh Medical Center.

Example: A patient who has been away at college reports complaining of stomach pain. He has received treatment from this physician, but the patient file indicates that his last visit was four years ago. In this scenario, though the physician has seen the patient in the past, the last visit occurred more than three years ago. Therefore, you would choose a code from the new patient outpatient services category ( CPT 99201 - 99205 ) rather than the established patient category (99211-99215).

If the same physician or other physician of the same specialty billing under the same group number sees the patient anytime within a three-year time frame, you must consider the patient -established,- even if the patient was seen at different locations or for a different diagnosis, says Cindy Parman,CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.

No Face-To-Face Service? Patient Is New

Experts generally interpret the new vs. established guidelines to apply to -professional services,- defined as face-to-face services rendered by a physician and reported by a specific CPT code[s], according to CPT 2007.

Therefore, if the physician (or another physician billing under the same group number) provides a non face-to-face service for a patient, and then provides the same patient a face-to-face service within three years, you should still consider the patient new when selecting an E/M code, Hvizdash says.

It is rare that a patient would receive a non-face-to-face service without seeing the physician at least once, says Parman. But if the physician does provide a service to the patient without face-to-face contact, then it should not count as a -professional service.-

Warning: The wording in the new/established patient flow chart may create confusion. The chart states that if a patient -received any professional service from a physician within the past three years,- he is established -quot; which could be read to mean that non-face-to-face services are also professional services.

However, on page 1 of CPT 2007, under the -New and Established Patient- heading, it reads: -for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician.-

Best bet: Keep a close eye on your new and established patient claims, and make sure you aren't downcoding new patient visits to lower-paying established patient encounters.

Different Specialties Can Make the Difference

When physicians of different specialties and different tax ID numbers see the same patient within the same 36-month period, the usual -new vs. established- rules do not apply, explains Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Specifically, if a physician of a different specialty -- or a subspecialist -- billing with a unique tax I.D. number -- sees a patient for the first time, you may consider the patient to be -new- even if he or she has seen other physicians within the group practice during the previous three years, Parman says.