Internal Medicine Coding Alert

Question: The internist performed the interpretation and report of a patient's ECG for another doctor, but she never met with the patient. Now this same patient has been referred to our office for treatment. Would I code this encounter as a new or established patient visit?

Indiana Subscriber

Answer: If your internist has reported an interpretation and report for a patient in the past -- for instance, 93010 (Electrocardiogram,routine ECG with at least 12 leads; interpretation and report only) -- this does not disqualify you from reporting a new patient code if the internist later sees the patient.

"An interpretation of a diagnostic test, reading an x-ray, or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient," states Medicare Claims Processing Manual, Chapter 12, Section 30.6.7. This means that if the internist only reviewed the patient's tracing but did not actively treat the patient, this patient still qualifies as a new patient upon the next face-to-face encounter with the internist.

If documentation supports coding a visit as a new patient level-five E/M service, for example, knowing the difference between new and established has an impact on your bottom line. The Medicare non-facility national  rate for a level-five new patient visit (99205, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity ...) pays $57.74 more than a level-five established patient visit (99215, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity ...) according to the 2010 Medicare Physician Fee Schedule.