Medicare Compliance & Reimbursement

Warning: Providers may be making crucial mistakes in E/M billing.

A recent transmittal from the Centers for Medicare & Medicaid Services lays out some important rules for new patient evaluation and management billing.

In transmittal 731, CMS fine-tunes its definition of "new patient" for E/M coding. Experts say the policy hasn't really changed, but CMS is explaining it differently, which should make things clearer.

Someone is a new patient if none of the office's physicians have seen her face-to-face in the past three years, according to the transmittal.

So if one of the physicians interpreted a patient's test results or did some other non-face-to-face service in the past three years, the office can still consider that person a new patient, says consultant Devona Slater with Auditing for Compliance & Education in Leawood, KS.

For example, a cardiologist performed an EKG interpretation for Patient Q but provided no face-to-face service during an emergency department visit three weeks ago. Today, Patient Q reports to the same cardiologist for a level-two E/M service.

Because the cardiologist did not see the patient for the EKG interpretation, the office can still bill a new patient E/M code for the visit, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, NJ, and a member of the National Advisory Board for the American Academy of Professional Coders (AAPC). On the other hand, if that cardiologist did examine the patient face-to-face, the claim can't designate her as a new patient.

The claim should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the visit.

The "new patient" rule applies to physicians in the same practice who are also of the same specialty, says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, GA and president of the AAPC National Advisory Board. If the practice in question is big enough and covers enough specialties, two physicians may often see a patient for completely different reasons, she says.

"If there is a large multi-specialty group and the endocrinologist sees the patient this year, but the cardiologist sees the patient next year, both are new patient visits," Parman says. If both see the patient in the same year, though, the physician's office should correct the coding and resubmit it.