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 [...]