Internal Medicine Coding Alert

Question: We have a new physician in our group whose patients from his previous group followed him to ours. Some of the staff argues that we should bill these patients' first visits in our clinic as new patient visits. Some believe we should bill them as established. What is the correct way to bill for these first visits in our clinic?

California Subscriber

Answer: The chief factors to consider when determining whether a patient is new or established are always time and physician. You must decide whether your physician has seen the patient in the past, and if he has, how long ago. These guidelines also apply to a new physician in your practice.

How it works: If the new physician in your clinic has provided 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 his 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 billed the patient for a professional service in the past three years, you'll report any subsequent visits with established patient E/M codes (such as 99211-99215).

Remember: Professional services that do not involve a face-to-face encounter, such as an x-ray or laboratory tests, do not count toward this rule. The services involved must include a face-to-face service and encounter.