Gastroenterology Coding Alert

Question: Our practice performed a test on a patient who was referred to us by another doctor. Our specialist was not present for the test; a lab tech performed the test. Should I consider this patient an established patient?

California Subscriber

Answer: No, you should consider the patient "new" until a face-to-face encounter with your specialist occurs.

If the primary 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 service.

According to AMA guidelines, there are additional factors to consider as well:

• The three-year rule is a well-established rule for "new" versus "established" patients. That is, if any physician within a given practice sees a patient within a 36-month period, that patient is considered "established."
• If visits occur outside of that time period, the patient would return to new patient status.
• If two specialists are of the same specialty and billing under the same group number, the three-year rule applies. If they work under different specialties or bill under different provider numbers, the second specialist may be able to report the patient as "new," as long as she hadn't seen that patient within the previous 36 months.

-- Clinical and coding expertise for this issue provided by Michael Weinstein,MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Marcella Bucknam, CPC, CCSP, CPCH, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.