EM 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 three 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.