Neurology & Pain Management Coding Alert

Knowing whether a patient is new or established is important; it also isn’t as easy as you might think.

Why? You’ll have to navigate a lot of nuance, even though it sounds straightforward. Despite all of the changes to evaluation and management (E/M) service coding in the past few years, however, CPT^® guidelines for new versus established patients have (thankfully) remained the same.

Here are four frequently asked questions and answers to help you know how to categorize any patient’s visit as new or established.

Know Why New/Established Is Important

Question: Why does the distinction matter?

Answer: First, “misidentifying a new patient as established poses a billing risk, as the reimbursement is higher for a new patient at the same level of service,” due to the extra work typically involved in taking the patient’s history and diagnosing new conditions, explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. For example, the 2024 Medicare national nonfacility fee for 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) is $89.39, whereas the fee for the corresponding new patient E/M service, 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.), is $109.69.

But the second reason your office needs to make the distinction correctly may be more important. “You could also be facing compliance issues,” Falbo warns.

Question: If a patient sees two providers with different specialties in the same practice, is the patient automatically established after the first E/M?

Answer: Often, different providers practicing in different specialties may be billing under the same group taxpayer identification number (TIN), making it seem like the billing is the same regardless of provider specialty. However, TINs are not the deciding factor to determine specialty and subspecialty differences. Providers may also have different specialty and/or taxonomy codes supporting the difference.

As an example, suppose a neurologist provides services to a patient, then, within a three-year period, the patient returns to receive services from a neurosurgeon. Both providers bill under the same practice TIN, but they have different specialty and taxonomy codes.

In this case, the patient’s first appointment with the neurologist would be coded as a new patient encounter, assuming the patient had not seen that provider or another neurologist in the group practice within the three years prior to that first appointment.

But the patient’s first appointment with the neurosurgeon would also be coded as a new patient encounter, given that the neurosurgeon’s specialty and taxonomy code should be different from the neurologist if properly credentialed. Or, to use language from the CPT^® guidelines, though they belong to the same group practice, they are not practicing within the exact same specialty and subspecialty.

Question: If a patient receives non-face-to-face services, does that make them established to the practice?

In this case, according to Medicare, the answer is no. Here’s why.

Medicare determines a new patient as one “who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.” This is similar to the CPT^® guidelines, which define professional services as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services.”

Question: If a patient follows a provider from one practice to a second, different practice, are they established to the second practice?

Answer: The answer to this question ethically is, yes, they are established to the physician (Provider A) they saw within the past three years. This has been outlined in a few Medicare Administrative Contractors’ (MACs’) FAQs, such as question No. 2 in the following: >https://www.ngsmedicare.com/en/web/ngs/evaluation-and-management-faqs?lob=96664&state=97178&rgion=93623&selectedArticleId=1510596.

However, for other payers who do not follow Medicare guidelines, since the second billing practice is a new TIN, and assuming that a different provider practicing in the same specialty as Provider A in the second billing practice has not seen the patient within the three years, then the patient is regarded as new to Provider A and the second practice.