Gastroenterology Coding Alert

Ask 2 key questions to pick the right code--and the right level--every time

When reporting most E/M services, you-ll need to know two things: Is the patient new or established? What are the documented levels of history, physical exam and medical decision-making (MDM)?

Here are quick instructions on how to use this information to select the correct E/M level every time. Face-to-Face in 3 Years Means Established Patient Generally, you should consider a patient to be established if any physician in your group practice (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months, says Marvel J Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. A recent CMS transmittal (R731CP, change request 4032, implemented Jan. 3) reiterated and reinforced the agency's policy on new and established patients.

Location isn't the issue: If your practice has multiple locations and a physician in location -A- sees the patient in January and a physician at location -B- sees the patient in December, the patient is still established. The need to create a new chart is inconsequential, Hammer says.

For instance: A primary-care physician recommends that a 60-year-old male see a gastroenterologist for a full workup. One of the physicians in your practice interpreted some test results for the same patient the previous year but provided no face-to-face service.

In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years, says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, Fla.

Another example: A patient comes to your office with a complaint of extreme heartburn and stomach pains. Although this is Gastro A's first time meeting the patient, Gastro B, in the same group practice, saw the patient two years ago for a similar complaint.

In this case, you should consider the patient to be established. Different Specialties Allow for Exceptions The new-patient rule applies when physicians in the same practice are also of the same specialty, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders- National Advisory Board.

Translation: If your practice is big enough and covers enough specialties, two physicians may see a patient for completely different reasons, Parman says. This could allow you to report a new-patient visit even though two physicians in the same practice saw the same patient within a three-year period.

Example: A general surgeon in a large multiple-specialty practice sees a patient in 2004 to remove some skin lesions. In [...]