Neurosurgery Coding Alert

Even if the patient has been to your office before, he might be new Proper coding for various E/M services (such as outpatient visits and rest home services) rests on determining whether a patient is "new" or "established," as defined by AMA guidelines. To make the proper selection, you-ll have to consider the following four points. -3-Year Rule- Still Applies If the physician (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, once again, 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, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, of MJH Consulting in Denver. Example: The neurosurgeon meets with a patient in the office at the patient's request (in other words, the service is not a consult). Although the surgeon has seen the patient in the past, the last visit occurred more than four years before. In this case, the patient is new rather than established. Therefore, you would choose a code from the new patient outpatient services category (99201-99205) instead of an established patient outpatient services code (99211-99215). Location Doesn't Factor In If the same physician or other physician of the same specialty billing under the same group number sees the patient at any time within a three-year timeframe, you must consider the patient "established," even if the patient was seen at different locations, Hammer says. Example: A group practice maintains two offices on separate sides of town. A patient sees surgeon A at location Y for a complaint of back pain. Six months later, the same patient sees surgeon B, in the same group practice, for a new complaint at location Z. In this case, the patient is established--- even though the encounters took place at separate locations and involved separate surgeons. Here's why: Because the surgeons are of the same specialty and billing under the same group number, the three-year rule applies. Had the surgeons been of different specialties--- or if they billed under different 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. Face-to-Face Matters As in past years, the "new vs. established" guidelines apply only to face-to-face services, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, CodeRyte Inc. coding analyst and coding review teacher. Therefore, if a physician (or another physician billing under the same group number) provided a non- face-to-face service for a patient and then [...]