How to Determine New vs. Established Patients in 2007
Published on Mon Jan 01, 2007
Even if the patient has been to your office before, she might be new Proper coding for various E/M services rests on determining whether a patient is -new- or -established,- as defined by AMA guidelines. To make the new-vs.- established decision easier, CPT 2007 includes a helpful flow chart: Now, a foolproof decision is only a few questions away. -3-Year Rule- Still Applies If your ob-gyn has never seen a patient before, that patient is automatically -new.- In addition, if the same ob-gyn hasn't seen the patient within the past 36 months, you may likewise consider the patient -new- from a coding standpoint, says Kathy Philp, CPC, COO of Momentum Revenue Services in Oklahoma City.
Example: Your ob-gyn meets with a patient in the office at the patient's request (in other words, the service is not a consult). Although the ob-gyn 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, so you would choose a code from the new patient outpatient services category (99201-99205) rather than the established patient outpatient services category (99211-99215).
If the same ob-gyn sees the patient anytime within a three-year timeframe, you must consider the patient to be -established,- even if the patient was seen at different locations.
In other words: Location isn't an issue when determining new vs. established.
Example: A group practice maintains two offices on separate sides of town. A patient with a complaint of abdominal pain sees general ob-gyn -A- at location -Y.- Six months later, the same patient sees general ob-gyn -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 ob-gyns.
Here's why: Because the ob-gyns are of the same specialty and billing under the same group number, the three-year rule applies. Had the ob-gyns been of different specialties -- or if they billed under different provider numbers -- the second ob-gyn 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. 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 provided a face-to-face service within three years, you should still consider the patient to be new when selecting an E/M service code for the face-to-face encounter.
Example: The ob-gyn meets with a patient for the first time for a new complaint. Another of the ob-gyns in the same practice interpreted some test results for the same patient [...]
