Internal Medicine Coding Alert

Question: We gave a flu shot a couple of months ago to the wife of a patient we were seeing that day. She asked the doctor for a flu shot because her husband is immuno-suppressed and she did not want to give him the flu. The wife was not our patient at the time. We billed only for a flu shot using 90658 and 90471, and no care was documented other than the flu shot (temperature and notation of arm injected). Yesterday, we saw the wife for her first visit with us to establish her as our patient. What is the correct way to bill her visit with us yesterday new or established? Illinois Subscriber

Answer: The key to answering your question is to know who administered the flu shot to the patient's wife: the physician or a nurse.

Both the AMA and CMS define a new patient as one who has not received any professional services from the physician or another physician with the same specialty in the same group within the previous three years. The Medicare Carriers Manual section 15502(A) further defines "professional services" as any "face-to-face service provided by the physician."

So, if the nurse provided the flu shot, the wife did not receive a "face-to-face service" from the physician, and you can code her current visit as a new patient encounter (99201-99205). This is similar to the scenario when practices set up flu-shot clinics during flu season. At these clinics, the physician does not order or directly supervise administration of the flu shot. If a person receiving a flu shot from a nurse at a clinic decides later to establish as a patient in the office, you can bill for a new patient visit.

Everything changes, though, if the physician administered the flu shot to the patient. He has provided a face-to-face service, so you would have to code the visit by the patient's wife to establish service as a visit from an established patient (99212-99215).

Although Medicare is clear regarding how it differentiates between new and established patients, this is a "gray" area of coding because individual carriers may interpret this scenario differently. You may wish to ask your payer for its interpretation to be certain you are coding correctly.

Answers to You Be the Coder and Reader Questions were provided by Kathy Pride, CPC, CCS-P, HIM applications specialist with QuadraMed, a national healthcare information technology and consulting firm based in San Rafael, Calif.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.