Neurosurgery Coding Alert

Tip: Scrutinize patient's relationship to physician before choosing an E/M code When your neurosurgeon provides an office or outpatient E/M service, the first question you have to ask before you can report the service is whether the patient is new or established. Learn how to differentiate the two and guarantee proper coding for your physician's work. CPT Provides Clear Definitions The chief factor in determining new versus established is time. You need to look at whether your neurosurgeon has seen the patient in the past, and if he has, how long ago.

Rule: To determine a patient's status, you should use CPT's established patient definition: -An established patient is one who received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.-

If the neurosurgeon has not provided professional services to a patient within the last three years, then you should use new patient E/M codes (such as 99201-99205), says Susan Allen, MBA, CPC, CCS-P, compliance coder with JSA Healthcare Corporation in St. Petersburg, Fla.

If your physician has billed a patient for a professional service in the past three years, you-ll report any subsequent visits as established patient E/M codes (such as 99211-99215), says Beth Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants in Winston-Salem, N.C. -I don't think a physician is often going to be billing for professional services that are not face-to-face, but if he provides a professional service, he has established a patient/provider relationship with that patient,- she says.

Tip: These guidelines apply even to a new surgeon in your practice. If your new neurosurgeon has provided professional services to a patient elsewhere within the last three calendar years, the patient is an established patient whether this is his first visit to your practice or not. Don't Focus on Location Look at your physician's specialty, time, and tax ID number, not location or insurer, when deciding a patient's status. CPT and CMS guidelines do not vary on the definition of a new or established patient.

Therefore, if a neurosurgeon provides professional services to a patient in the hospital, any neurosurgeon who has the same tax identification number and provides subsequent office or outpatient care must consider the patient an established patient and bill the appropriate established patient office visit code (99211-99215). The place of service is irrelevant to the new/established patient definition; new or established refers to the patient's relation to the physician(s), not the patient's relation to the office, Janeway says.

Example: A neurosurgeon in your group provides an inpatient consult to a 1-year-old child he's never seen before. The patient then comes to your office for follow-up care one week later. You should [...]