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 report an established patient office visit for the physician's in-office follow-up (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) because the neurosurgeon performed the follow-up care within three years of the hospital encounter (such as 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). The patient is an established patient even though he has never been to your office.

The same coding applies if the neurosurgeon who saw the patient in the hospital is unavailable and the patient is assigned to another neurosurgeon in the same practice. Even though the second physician has never seen the infant, a neurosurgeon who is in the same specialty and group has provided professional services within the past three years, which meets CPT's definition of an established patient.

No E/M Service Means New Patient

Medicare defines -professional services- as any E/M or face-to-face service. When a neurosurgeon provides services to a patient, and another neurosurgeon in the same group furnishes services before three years have elapsed, you should consider the patient established.

-If no evaluation and management service is performed, the patient may continue to be treated as a new patient,- according to the Medicare Carriers Manual (MCM) section 30.6.7.

Pay Attention to Multi-Specialty Guidelines

Remember that the rules differ for subspecialties. If your practice has subspecialists, you could potentially have a situation in which you would use new patient E/M codes for an otherwise established patient.

If a subspecialist has a tax identification number that is different from that of the general group tax identification number, you may consider the patient receiving professional services from that subspecialist to be a new patient per the June 1999 CPT Assistant, says Stacie L. Buck, RHIA, LHRM, president and founder of Health Information Management Associates Inc. in North Palm Beach, Fla. It's also important to familiarize yourself with how your individual carriers define new and established patient visits with regard to different subspecialties in the same group, she adds.

The difference: The subspecialist must have a unique taxonomy code for his subspecialty, and the patient must not have seen any other physician who provides services of the subspecialty for the practice within the last three years (see www.wpc-edi.com/codes/taxonomy for a list of all specialties).

Best bet: Obtain written confirmation from the payer as to its specific requirements. Each carrier and payer may vary on what counts as -different specialties.-

Public-relations consideration: Although you can technically count the patient as -new- in these scenarios, good patient relations may dictate that you bill the encounters as established. Patients may question why you-re charging them as new when they-ve been patients in the practice. This is especially true if the patient's coinsurance is a percentage of the allowed amount. Insurers usually pay new patient codes at a higher allowance than established patient codes.