Neurology & Pain Management Coding Alert

Question: We had a patient seen for a consultation in a hospital, and our physician billed 99255 (Inpatient consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity&). After discharge, the patient was not instructed to follow up at our office.
Eight months later, the patient called in and wants to see our same physician because the patients vertigo is getting worse. Should we consider this patient established to our practice even though he has never been to our office? We have no office medical record on him. Is this is a new or established patient visit?

Florida Subscriber

Answer: According to CPT, the patient is considered established because eight months ago your physician provided face-to-face professional services for the patient. A new patient is one who has not been seen by your physician or practice in three years.

Example: If Dr. Jones, a neurologist, sees Mr. Smith in the emergency room at the request of the ER physician for a problem, and then 22 months later Mr. Smith sees Dr. Lee, a neurologist who is in the same group as Dr. Jones, in their office for the same or even a different problem, Mr. Smith would be established to both Dr. Jones and Dr. Lee because he was seen by Dr. Jones less than three years prior.

Exception: If Mr. Smith has not received a face-to-face professional service within the past three years by the provider or a provider of the same specialty within the same group, consider him a new patient. Suppose Dr. Jones performs only the professional interpretation of a diagnostic study for Mr. Smith and never sees Mr. Smith face-to-face in the hospital. Twenty-two months later, Mr. Smith sees Dr. Lee in the office for the same or a different problem. In this case, Mr. Smith would be considered to be a new patient to Dr. Lee.