Gastroenterology Coding Alert

Even if the patient has been to your office before, she might be new

The responsibility of determining whether a patient is new or established, as defined by AMA guidelines, rests on your shoulders. To make the new-vs.-established decision easier, CPT 2007 includes a helpful flow-chart: Now, a foolproof decision is only a few questions away.

-3-Year Rule- Still Applies

If your gastroenterologist has never seen a patient before, that patient is automatically new. And if the same gastroenterologist hasn't seen the patient within the past 36 months, you may likewise consider the patient new from a coding standpoint, says Kelly Crissinger, a gastro office manager and coder/biller at Dr. Nayeem Akhtar/Dr. Donald Douglas in Sunbury, Pa.

Example: Your gastroenterologist meets with a patient in the office at the patient's request (in other words, the service is not a consult). Although the gastroenterologist has seen the patient in the past, the last visit occurred more than four years before. In this case, the patient is new rather than established, says Edwin Elson, practice manager for Pediatric Gastroenterology and Nutrition of Tampa Bay in Florida. Therefore, you would choose a code from the new patient outpatient services category (99201-99205) rather than the established patient outpatient services category (99211-99215)

If the same gastroenterologist sees the patient anytime within a three-year timeframe, you must consider the patient to be established, even if the patient was seen at different locations, Crissinger says.

In other words: Location isn't an issue when determining new vs. established. 

Example: A group practice maintains two offices on separate sides of town. A patient sees general gastroenterologist A at location Y for a complaint of abdominal pain. Six months later, the same patient sees general gastroenterologist B in the same group practice at location Z for a new complaint. In this case, the patient is established -- even though the encounters took place at separate locations and involved separate gastroenterologists. -This is established, if this is the same practice,- Elson says.

Here's why: Because the gastroenterologists are of the same specialty and billing under the same group number, the three-year rule applies. Had the physicians been of different specialties -- or if they billed under different provider numbers -- the second gastroenterologist may have been able to report the patient as new, as long as she hadn't seen that patient within the previous 36 months.

Face-to-Face Matters

As in past years, the new-vs.-established guidelines apply only to face-to-face services. Therefore, if a physician (or another physician billing under the same group number) provided a non-face-to-face service for a patient and then provided a face-to-face service within three years, you should still consider the patient to be new when selecting an E/M service code for the face-to-face encounter.

Example: The gastroenterologist meets with a patient for the first time for a new complaint. Another of the gastroenterologists in the same practice interpreted some test results (such as a 24-hour pH study) for the same patient the previous year but provided no face-to-face service.

In this case, the gastroenterologist providing the current service may still consider the patient to be new when selecting an initial E/M code because no physician within the group practice provided the patient with a face-to-face service within the past three years.

Different Specialties Can Make the Difference

When physicians of different specialties see the same patient within the same 36-month period, the usual new-vs.-established rules do not apply.
 
Specifically, if a physician of a different specialty -- or a subspecialist billing with a unique tax identification number -- sees a patient for the first time, you may consider the patient to be new even if she has seen other physicians within the group practice during the previous three years.

Example: A gastroenterologist in a multiple-specialty practice sees a patient in 2005 for a gastric adenoma treatment. In early 2007, the same patient sees the oncologist (a member of the same multispecialty practice) for an office E/M service regarding the results of an abnormal colonoscopy.

-The oncologist can consider this a new patient visit,- Crissinger says. Because the gastroenterologist and oncologist (who are obviously of different specialties) saw the patient for completely unrelated problems (this is key), you would report the gastroenterologist's initial visit and the oncologist's initial visit with the patient using the new patient codes (99202-99205).