Gastroenterology Coding Alert

Reader Questions:

Is This ‘New’ Patient Truly New?

Published on Mon Jan 24, 2022

Question: A GI provider in our large practice saw a patient, and the patient was billed for a new patient E/M visit. Several weeks later, the patient was referred to a general surgeon within the same practice who has a different taxonomy code from the first doctor. Is this patient now considered established, or do we charge a new patient E/M for the general surgeon?

Texas Subscriber

Answer: Per CPT^®, a new patient is defined as “one who has not received any 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” (emphasis added).

In your case, even though the two providers are practicing in the same practice, they are practicing under different taxonomy codes, meaning they are practicing in different specialties. This would be true even if both providers are billing under the same group taxpayer identification number (TIN).

This means the patient is regarded as a new patient to the general surgeon. So, you can go ahead and bill a new patient E/M for the patient’s visit to the general surgeon, assuming neither the surgeon nor another physician or qualified healthcare professional of the same specialty and subspecialty has seen the patient within the three years prior to the current E/M visit.