EM Coding Alert

This tool will help you navigate the sometimes tricky new vs. established question.

As noted in “Pay Attention to 3-Year Rule to Decide Between New vs. Established Codes” on page 3 of this issue, before you can determine which code to report for a patient’s office visit, you need to first determine if he qualifies as a new or established patient. By asking five questions, you can quickly uncover the correct answer every time.

Keep this tool handy and refer to it as you decide between 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) and 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …).

1. Has the patient ever received any professional services from any physician in this group?

         No: The patient is new.                                                                                                              Yes: Go on to question #2.

2. Within the past three years, has the patient received any professional service from a particular physician, who is now reporting a service?

         Yes: The patient is established.                                                                                                No: Go on to question #3.

3. Has the patient received any professional service from a physician in the group of the same specialty, within the past three years? (CPT^® defines professional services as those face-to-face services rendered by a physician and reported by a specific CPT^® code.)

         No: The patient is new.                                                                                                              Yes: Go on to question #4.

4. Has the patient received care from a physician of the exact same specialty within the past three years, or is a physician of a different subspecialty now providing care?

         The providing physician is of the same specialty: The patient is established.

         The providing physician is of a different subspecialty: Go on to question # 5.

5.  Does the current providing physician have the same tax ID as the physician who provided a separate service with in the past 36 months?

         Yes: The patient is established.                                                                                                No: The patient is new.

Note: You can also find a similar flow chart on page 2 of the Evaluation and Management (E/M) Services Guidelines portion of CPT^® 2013: Professional Edition, published by the AMA.