Internal Medicine Coding Alert

It seems simple that internal medicine practices should be able to easily report office/outpatient evaluation and management (E/M) codes 99201-99205 for new patients and E/M codes 99211-99215 for established patients, according to CPT. But, exactly what is an established patient? And, what if you are a sole practitioner who becomes part of a new, larger internal medicine group practice or multi-specialty clinic? Are the patients you have seen for years established patients or are they new patients because they are new to the group? What about patients who visit your office once, but then arent seen again for another five years? They may have completely new health conditions or concerns. Are they still established patients because they have been seen in the office before?

The answers can be tricky.

The basic rule is, if you have been seen in that practice within the past three years, then you are an established patient, advises Jim Stephenson, the billing manager for Premium Medical Management Services Inc., a multi-specialty physician group in Elyria, OH. Even if a patient has been seen by only one physician in the group and then sees another physician for the first time, the patient is still an established patient.

But, if the patient has not been seen in the practice for three years or more, then, according to CPT rules, the patient should be considered a new patient.

I think the idea is that the physician group will have to do the same amount of work for this patient as for a patient that has never been seen by the group, because so much time has passed, Stephenson advises.

Surprisingly, for new group practices with new billing identification numbers for Medicare and other third-party payers, all patients of the new group are considered new patients. We just went through this with setting up our group, Stephenson says.

He sought the advice of outside coding consultants who advised that even patients who had been seen by the individual physicians prior to the formation of the group practice should be considered new patients of the new group.

The thing that is confusing is if you have an established practice and you bring a new physician in,
he continues.

In that situation it could vary depending on how the physician is set to bill third-party payers. But, in most cases, the established patients of the practice who are seen by the new physician would still be considered established patients because they had been seen in the group within three years.