Gastroenterology Coding Alert

Question: We hired a new physician for our practice after another physician left. The new physician thinks he should be able to bill 99205 since the patients are new to him. The patients, however, are not new to the practice. Due to the visits' complexity and since the encounters are follow-ups within the same practice, should these services be 99215?

North Dakota Subscriber

Answer: Generally speaking, this is not a new patient scenario, and 99201-99205 (Office or other outpatient visit  for the evaluation and management of a new patient ...) is not appropriate. "New patient" means a patient who has not received any professional services, such as an E/M service or other face-to-face service (like a surgical procedure) from the physician or physician group practice -- with the same physician specialty -- within the past three years.

If a professional component of a previous procedure is billed in a three year period, such as when a lab interpretation is billed and no E/M service is performed, then the patient remains a new patient for the initial visit, according to the Medicare Claims Processing Manual. For instance, interpreting a diagnostic test or reading an x-ray or an electrocardiogram (EKG) in the absence of an E/M service or other face-to-face service with the patient does not affect the new patient designation.

If you are using the same tax ID number, the established patients are still established, and you should use 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

The new physician could bill for a higher level of care if he is going to have to treat a new problem that would need more details than previously noted in the chart.