EM Coding Alert

Find out what to do if a patient follows a provider.

Figuring out whether a patient is new or established can mean navigating a lot of nuance, even though it sounds straightforward. Luckily, despite all of the changes to E/M service coding in the past few years, the CPT^® guidelines for new versus established patients have remained the same.

Here are four frequently asked questions and answers to help you know how to categorize any patient’s visit as new or established.

Understand Why the Categories Exist

Question: Why does the distinction matter?

Answer: First, “misidentifying a new patient as established poses a billing risk, as the reimbursement is higher for a new patient at the same level of service,” due to the extra work typically involved in taking the patient’s history and diagnosing new conditions, explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. For example, the 2023 Medicare national nonfacility fee for 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) is $90.82, whereas the fee for the corresponding new patient E/M service, 99203, is $112.84, a difference of $22.02.

But the second reason your office needs to make the distinction correctly may be more important. “You could also be facing compliance issues,” Falbo warns.

Rely on TIN Versus Taxonomy Codes

Question: If a patient sees two providers with different specialties in the same practice, is the patient automatically established after the first E/M?

Answer: Often, different providers practicing in different specialties may be billing under the same group taxpayer identification number (TIN), making it seem like the billing is the same regardless of provider specialty. However, TINs are not the deciding factor to determine specialty and subspecialty differences. Providers may also have different specialty and/or taxonomy codes supporting the difference.

As an example, suppose a surgical oncologist provides services to a patient, then, within a three-year period, the patient returns to receive services from a medical oncologist. Both providers bill under the same practice TIN, but they have different specialty and taxonomy codes.

In this case, the patient’s first appointment with the surgical oncologist would be coded as a new patient encounter, assuming the patient had not seen that provider or another surgical oncology physician in the group practice within the three years prior to that first appointment. But the patient’s first appointment with the medical oncologist would also be coded as a new patient encounter, given that the medical oncologist’s specialty and taxonomy code should be different from the surgical oncologist’s if properly credentialed. Or, to use language from the CPT^® guidelines, though they belong to the same group practice, they are not practicing within the exact same specialty and subspecialty.

Count on the Medicare Non-Face-to-Face Rule

Question: If a patient receives non-face-to-face services, does that make them established to the practice?

In this case, according to Medicare, the answer is no. Here’s why.

Suppose an oncologist in a specific practice interprets a patient’s blood test results and sends the report to the patient’s primary care physician (PCP). Then that same patient returns within three years to see another oncologist in that same practice for a suspicious lump in the breast.

In this situation, the patient did not receive face-to-face services from the first oncologist. According to section 30.6.7.A of the Medicare Claims Processing Manual, “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).

In other words, Medicare determines a new patient as one “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.” This is similar to the CPT^® guidelines, which define professional services as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services.”

Do This When Patients Follow Providers

Question: If a patient follows a provider from one practice to a second, different practice, are they established to the second practice?

Answer: The answer to this question ethically is, yes, they are established to the physician (Provider A) they saw within the past three years. This has been outlined in a few Medicare Administrative Contractors’ (MACs’) FAQs, such as question No. 2 in the following: >https://www.ngsmedicare.com/en/web/ngs/evaluation-and-management-faqs?lob=96664&state=97178&rgion=93623&selectedArticleId=1510596.

However, for other payers who do not follow Medicare guidelines, since the second billing practice is new a TIN, and assuming that a different provider practicing in the same specialty as Provider A in the second billing practice has not seen the patient within the three years, then the patient is regarded as new to Provider A and the second practice.