Internal Medicine Coding Alert

Answer: CPT rules and third-party payer policies in this area make the answer to this question complicated.

According to CPT 2000, a new patient is a patient who has received no professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

According to the CPT Assistant, the determining factor in assigning an evaluation and management code for new vs. established patients is whether the patient received professional services from the physician within the past three years regardless of the place of service. Thus, if the patient has received professional services from the same physician within the past three years, the patient is considered an established patient, even though the physician has changed medical groups.

Bret Baker, a third-party relations specialist with the American College of PhysiciansAmerican Society of Internal Medicine in Washington, D.C., echoes this position. CPT is pretty clear in stating that if the physician or one in the same group who is of the same specialty has seen the patient within three years, that patient is considered an established patient, he advises.

Also, the CPT Companion, also published by the American Medical Association, makes reference to the fact that even if a physician sees the patient for the first time as an inpatient and the patient is later seen in the office, the office visit would be coded as an established patient visit, even though that is the first time the patient is in that office. While this does not exactly describe the situation above, I think it indicates that the definition is based on whether the patient is seen by a particular physician, not on site of service.

However, for most payers, including Medicare, physicians in a group are issued a single provider number and bill the payer as one provider.

When one physician leaves a group, is issued a new provider number and sees patients at a new office, which requires generating a new patient record, would this not equal the work involved in seeing that patient for the first time?

Not necessarily, advises Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement consultant in North Augusta, S.C. I have been told that Medicare tracks physicians by UPIN (unique physician identification number), which stays the same for the individual physician regardless of the provider number. Each claim has the provider number and the UPIN of the treating physician.

But, some commercial payers, managed care plans, and even some Medicare carriers have different policies about billing established vs. new patients, she adds. For example, if a patient has an ECG performed in the hospital and a cardiologist performs the interpretation, he or she has provided a professional service, to the patientwithout seeing the patient face-to-face. A strict interpretation of CPT rules would hold that the patient would be considered an established patient in the event that cardiologist sees him at a later date. However, many payers allow a physician who has never provided face-to-face treatment to bill the patient as a new patient the first time the patient is seen.

I would advise that you check this out with all of your payerscommercial, managed care and Medicare carriersto find out what they think. Ask them specifically, she says. And, even though you do not have access to the old medical records of patients at another practice, if that patient requests that his or her records be sent to your new office, the old practice is required to comply.