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Internal Medicine Coding Alert

Reader Question:

First Office Visit for Former Hospital Patient

Published on Sat Dec 01, 2001

Question: When a patient presents to the office for the first time after hospital discharge, can the new patient code be used if a different doctor from the one he saw in the hospital sees him? CPT says a new patient is one who has not been seen in the past three years, but I have also heard that a new patient is one who requires a medical record to be established.

Oregon Subscriber
 
Answer: The CPT guidelines on this matter are clear:  A new patient is one who has not 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. An estab-lished patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.
 
There is nothing in the CPT guidelines that bases the classification of a new or established patient on the fact that he does or does not have a medical record established with your office. The fact that you have to create a medical record is irrelevant to the type of visit that is coded. If the same physician who saw the patient in the hospital sees the patient in the office for the first time, this would be coded as an established patient visit. If a different physician in your practice of the same specialty sees the patient in the office, this would also be coded as an established patient examination. If you have subspecialists in your practice, and medical necessity dictates that the patient be referred to a physician of a different subspecialty in your group for follow-up, and if a full new patient workup is performed and is medically necessary, you may bill a new patient workup for the subspecialist. However, if the patient sees the subspecialist only for general follow-up or because that physician has an open appointment, you would code an established patient examination, e.g., 99212-99215.

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