Neurosurgery Coding Alert

Question: I work for a doctor who just left a large group practice to start his own practice. Some patients followed him from the old practice to the new. Should they be considered new patients or established patients?

New Jersey Subscriber

Answer: CPT 2000 describes a new patient as one who has not 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, notes Brenda Messick, CPC, senior consultant at Gates, Moore & Co., a physician practice management firm in Atlanta. This rule holds true regardless of any billing arrangements. Therefore, if the physician saw the patient at his previous practice within the past three years, that patient should be billed as an established patient. The intent of the higher reimbursement for new patients is due to the fact that the physician lacks clinical knowledge of the patient. Consequently, extra work and decision-making will be involved with his or her assessment of the patient.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, a coder who specializes in neurological procedures, notes that CPT clearly defines the group as having the same tax identification (ID) number. But the guidelines refer to services provided by the physician or another physician [in] the same group, so even if all the neurosurgeons under the former group practice used the same tax ID number and the neurosurgeon striking out with his new practice bills under a new tax ID number, Medicares rules still apply. Bill as an established patient.