General Surgery Coding Alert

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

Proper coding for various E/M services (such as outpatient visits and rest home services) rests on determining whether a patient is -new- or -established,- as defined by AMA guidelines.

To make the -new vs. established- decision easier, CPT 2007 includes a helpful flowchart.  Now, a foolproof decision is only a few questions away.

-3-Year Rule- Still Applies

If the physician (or any physicians of the same specialty billing under a common group number) has never seen a patient before, that patient is automatically -new.- In addition, if the same physician (or, once again, any physicians of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient -new- from a coding standpoint, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Example: The surgeon meets with a patient in the office at the patient's request (in other words, the service is not a consult). Although the surgeon 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. Therefore, you would choose a code from the new patient outpatient services category (99201-99205) instead of an established patient outpatient services code (99211-99215).

Location Doesn't Factor In

If the same physician or other physician of the same specialty billing under the same group number sees the patient at any time within a three-year timeframe, you must consider the patient -established,- even if the patient was seen at different locations, Hammer says.

Example: A group practice maintains two offices on separate sides of town. A patient sees general surgeon A for a complaint of bowel pain at location Y. Six months later, the same patient sees general surgeon B, in the same group practice, for a new complaint at location Z.

In this case, the patient is established -- even though the encounters took place at separate locations and involved separate surgeons.

Here's why: Because the surgeons are of the same specialty and billing under the same group number, the three-year rule applies. Had the surgeons been of different specialties -- or if they billed under different provider numbers -- the second surgeon 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, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, CodeRyte Inc. coding analyst and coding review teacher. 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.

Example: The surgeon meets with a patient for the first time for a new complaint. Another of the surgeons in the same practice interpreted some test results for the same patient the previous year but provided no face-to-face service.

In this case, the surgeon 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, Jandroep says.
 
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 he has seen other physicians within the group practice during the previous three years.
 
Example: An internist in a multiple-specialty practice sees a patient in 2005 for diabetes treatments. In early 2007, the same patient sees the general surgeon (a member of the same multi-specialty practice) for an office E/M service regarding a new complaint.

Because the internist and general surgeon (who are obviously of different specialties) saw the patient for completely unrelated problems (this is key), you may report the surgeon's initial visit with the patient using the new patient codes.