EM Coding Alert

Question:If a patient is referred to our practice for otitis media in 2014 from Dr. Smith and then is referred back to us in 2015 for tonsillitis by Dr. Jones. Is the patient new or established for the 2015 visit?

Georgia Subscriber 

Answer: The patient is established, and you should report an E/M code in the 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) range for the 2015 encounter. 

Here’s why: The chief factor in determining whether a patient is new or established is time. You must decide whether you have seen the patient in the past, and if you have, how long ago. CPT® clearly defines what qualifies as an established patient: “An established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

As noted in the definition, the new patient rule applies when physicians in the same group practice are also of the same specialty. If the patient has been seen before within the same practice, even though he switched doctors, he is an established patient. In your case, the patient is an established patient because a physician in the same specialty and group provided professional services within the past three years.

If you are in a group physician setting, under the same tax ID, you have to determine if the patient has seen any of the doctors (of the same specialty) and, if so, when, before you can decide on a new or established patient code.

Exception: The rules differ for subspecialties. If your practice has sub-specialists, you may have a situation when you should use new patient E/M codes for an otherwise established patient. Check with your individual payers to see how they define new and established patient visits with regard to different specialties and sub-specialties in the same group.