General Surgery Coding Alert

Question: We saw a patient over a year ago for a hemorrhoidectomy, and now the patient came back with extreme lower right quadrant pain and our surgeon performed an appendectomy. Should we  bill the appendectomy as a new patient since he's coming back for a different reason?

Idaho Subscriber

Answer:  No, you should not bill this case as a new patient. You should bill this as an established patient for several reasons.

If your surgeon sees a patient any time within a 36-month period, that patient is considered established, regardless of the reasons for the visits. This is the AMA's "three-year rule." You should go by this rule even if another physician in your practice sees the patient, as long as it's within the 36 months.

Caveat: This rule applies as long as all the physicians in your group bill under the same group number.

Location is not a factor either, in the event your practice has more than one location.

Distinction: The rules change a bit if you are operating in a multi-specialty practice. If a physician of a different specialty sees a patient for the first time, you may consider the patient to be "new" even if he has seen other physicians in other specialties within the group practice during the previous three years.