General Surgery Coding Alert

Question: We have a new general surgeon in our group who is now treating one patient from their previous practice. Do we treat this as a new or established patient?

California Subscriber

Answer: The answer depends on how long it has been since the new surgeon has treated the patient. The chief factor in determining whether a patient is new or established is always time.

How it works: If the surgeon new to your practice has provided face-to-face professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is their first visit to your practice.

Rule: To determine a patient’s status, use CPT^®’s established patient definition: “An established patient is one who received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.”

If your physician has seen the patient for a professional service in the past three years, you’ll report any subsequent visits with established patient evaluation and management (E/M) codes (such as 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Remember: Professional services that do not involve a face-to-face encounter, such as interpreting an X-ray or reviewing laboratory tests without seeing the patient, do not count toward this rule. The services involved must include a face-to-face service and encounter.