Neurosurgery Coding Alert

Patient been to the office before?

She might still be -new- for E/M claims

When a patient reports to the neurosurgeon for an evaluation and management (E/M) service, the onus is on the coder to decide whether the patient is new or established -- and this task may not always be as easy asit seems.

Help is here: To make the new-versus-established decision easier, CPT 2007 includes a flow chart making an accurate decision only a few questions away. As long as you follow the proper path when reporting new and established patient E/Ms, you-ll get it right every time.  

Be Sure to Apply -3-Year Rule-

If the neurosurgeon (or any physicians of the same specialty billing under a common group number) has never seen a patient before, that patient is automatically -new.- In addition, if the same physician (or any physicians of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient -new- from a coding standpoint, confirms Suzan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician educator for the department of surgery at the University of Pittsburgh Medical Center.

Example: The neurosurgeon meets with a patient in the office at the patient's request (i.e., the service is not a consult). Although the surgeon has seen the patient in the past, the last visit occurred five years ago. Therefore, you would choose a code from the new patient outpatient services category (99201-99205) rather than the established patient category (99211-99215), says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.

If the same physician or another physician of the same specialty billing under the same group number sees the patient anytime within a three-year timeframe, you must consider the patient -established,- even if the patient was seen at different locations or for a different diagnosis, Parman says.

Example: A neurosurgery practice maintains two offices in adjoining towns. A patient with a complaint of radiculitis sees Neurosurgeon A at location Y. Six months later, the same patient sees Neurosurgeon B, in the same group practice, for a new complaint of upper back pain at location Z.

In this case, the patient is established -- even though the encounters took place at separate locations for separate conditions and involved separate surgeons, Parman says.

Had the surgeons been of different specialties -- or if they billed under different tax ID numbers (not provider numbers) -- the second surgeon may have been able to report the patient as new, as long as she hadn't seen that patient within the previous 36 months, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

No Face-to-Face Service? Patient Is New

Experts generally interpret the new-versus-established guidelines to apply to -professional services,- defined as face-to-face services rendered by a physician and reported by a specific CPT code, according to CPT 2007.

Therefore, if a neurosurgeon (or another physician billing under the same group number) provides a non-face-to-face service for a patient, and then provides the same patient a face-to-face service within three years, you should still consider the patient new when selecting an E/M code, Hvizdash says.

Example: Neurosurgeon X holds an initial encounter with a patient complaining of severe headaches. The neurosurgeon performs a level-two E/M. The patient's file indicates that a different surgeon in the practice interpreted CAT scan test results for the same patient eight months ago but provided no face-to-face service.

Since the neurosurgeon who interpreted test results did not meet the patient in person, the patient had not received any professional services before seeing Neurosurgeon X. On the claim, you should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the encounter.

It is rare that a patient would receive a non-face-to-face service without seeing the neurosurgeon at least once,  Parman says. But if the surgeon does provide a service to the patient without face-to-face contact, it should not count as a -professional service.-

Warning: The wording in the new/established patient flow chart may create confusion. The chart states that if a patient -received any professional service from a physician within the past three years,- he is established -- which could be read to mean that non-face-to-face services are also professional services.

However, on page 1 of CPT 2007, under the -New and Established Patient- heading, it reads: -for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician.-

Best bet: Keep a close eye on your new and established patient claims, and make sure you aren't downcoding new patient visits to lower-paying established patient encounters.

Different Specialties Can Make the Difference

When physicians of different subspecialties and different tax ID numbers see the same patient within the same 36-month period, the usual -new versus established- rules do not apply, Brink says.

Specifically, if a physician of a different specialty -- or a subspecialist billing with a unique tax I.D. number -- sees a patient for the first time, you may consider the patient to be -new- even if he has seen other physicians within the group practice during the previous three years, Parman says.

Explanation: Since group practices are typically defined as those having a common tax ID number, a subspecialist billing under a different tax ID would not be considered part of the group for purposes of deciding whether -new- or -established- applies. This means that subspecialists using the same tax ID number will not be able to bill a -new- patient visit for a patient seen by another physician in the same specialty within the previous three years.