Medicare Compliance & Reimbursement

Question: A patient came to our office and saw one neurologist, but when the patient came back for a followup he saw a different neurologist who ended up taking over the patient's case. The two physicians have different provider numbers and tax ID numbers. Their only connection is that they work out of the same hospital and "cover" for one another if one is out of town, which is what happened here. My guess is to use 99201 for the initial encounter and 99231 for the follow-up. Is that correct?

Answer: If the encounters occurred in an outpatient setting, then no. When one neurologist (we'll call her Neurologist A) sees a patient for the first time, you would use one of the office/ outpatient E/M codes (99201 -- 99215, Office or other outpatient visit for the evaluation and management of a new patient...). When another physician(Neurologist B) is covering for Neurologist A, the covering physician should treat any of Neurologist A's patients as established, and use 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...).

If the patient decides to continue treatment with Neurologist B instead of A, you should still code subsequent visits with 99212.

Backup: CPT's E/M Section guidelines state: "In the instance where a physician is on call for or covering for another physician, the encounter will be classified as it would have been by the physician who is not available." The codes you mention are for hospital care (99221-- 99233, Initial/Subsequent hospital care, per day, for the evaluation and management of a patient). If the site of service is, in fact, an inpatient hospital setting, then there is no difference between a new and established patient. You would simply use the appropriate code, such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient...) for encounters with both neurologists, assuming that all three of the E/M service requirements are met.