Internal Medicine Coding Alert

Question: My physician sees a new Medicare patient for the first time in the hospital (as an inpatient) and the patient later decides to follow up in our office. Can my physician still report her as a new patient?

Maine Subscriber

Answer: Since your physician saw the patient and provided medical care, regardless of the setting, when the patient comes into your office, she is established. Choose an appropriate established outpatient E/M, such  as 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician.

Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). CPT states that if your physician has provided any services for the patient in the past three years, the patient is established.