Neurosurgery Coding Alert

Here's why the new-established question matters more than ever for your surgeon.

Let's say your neurosurgeon provides a new patient with a standard office E/M service (99201-99215). In your haste, you choose an established patient code for the encounter. This mistake will hurt the practice twofold: you've submitted an incorrect code and this miscode will cost the practice deserved reimbursement.

Say Goodbye to Consult Codes for Most Providers

Throw in Medicare's deletion of consultation codes, and it's clear that the difference between a new and established patient is even more vital than in previous years. For Medicare payers, and payers that follow their lead, coders will now have to "select the correct code, new or established, to bill for what used to be consults that did not have a new versus established component concept," relays Quinten A. Buechner, M.S., M.Div., AAPC:CPC, BMSC:ACS-FP/GI/PEDS, ACMCS:PCS, PHIA:CCP, PAHCS:CMSCS, president of ProActive Consultants,LLC in Cumberland, Wis.

Good news: We've got the experts' advice on nailing the patient's status every time. Count Backward From 3, Arrive at Answer If your patient has had a face-to-face service with the neurosurgeon (or another physician with the same specialty credentials in your group) within the last three years, then the patient is established, confirms Kami Culb, office coordinator at Frederick Memorial Hospital in Frederick, Md.

Example: A patient reports to Dr. N, a neurosurgeon in your practice, on May 15, 2010. The patient's record indicates that she received a face-to-face E/M service from Dr. P, another neurosurgeon in your practice, on Dec. 1, 2009. Notes indicate an expanded problem focused history and exam, and lowcomplexity medical decision making.

This is an established patient, so you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the encounter.

Ensure Physician Communication in Group Setting

It's not too confusing for multi-specialty/multi-surgeon practices to keep track of new and established patients- as long as there is adequate communication among neurosurgeons. If there is poor communication either among surgeons or specialties, however, you could end up miscoding your neurosurgeon's 99201-99215 services, warns Marianne Wink, RHIT, CPC, ACS-EM, a coder specializing in neurological issues based in Rochester, N.Y.

Best bet: Double-check all initial subspecialty outpatient visits before deciding patient status to prevent miscoding a 99201-99215 service.

(Note: While there are some exceptions, non-Medicare payers generally adhere to Medicare's new/established patient rules. If you are unsure about the status rules for a private payer, check out your contract before filing a claim.)

Confirm Face Time or Forget 99211-99215

So let's say Dr. N provides treatment for a patient within the last three years " but the treatment did not involve face-to-face service. Is this patient new or established?

Expert input: If the physician does not physically see the patient, then the patient cannot be considered established, confirms Shelby Davidson, CPC, CMSCS, coding educator at OHMFS in Ohio. "Interpret the phrase 'new patient'' to mean a patient who has not received any professional services - in other words, an E/M service or other face-to-face service - from the physician or physician group practice within the previous three years," she recommends.

This means that you might be able to report a patient as new if Dr. N provided services for the patient less than three years ago - provided it was not a face-to-face-service.

Example: A patient reports to Dr. N for an E/M service on June 1, 2010. The patient's record indicates that Dr. N read and interpreted the results of the patient's vertebral x-ray on May 5, 2009. There was no record of a face-to-face service. You should choose a new patient E/M code for this encounter (99201-99205).

Explanation: When the physician "reads an x-ray, EKG, etc., in the absence of an E/M service or other face-to- face service with the patient, it does not affect the new patient designation," explains Davidson.

Check Specialty When Deciding Status

Coders that work in multispecialty practices will have to pay attention to one more new/established patient status rule.

Example: You are a coder for Dr. N, a neurosurgeon who is part of a multispecialty practice that also includes cardiology services. A patient reports to Dr. N for an E/M service on March 15, 2010. The patient's medical record indicates that he received a covered cardiology screening from Dr. C, the practice's cardiologist, a year ago. The patient has not, however, seen Dr. N within the practice in the past three years.

You would code this as a new patient, since the specialty is different.