Oncology & Hematology Coding Alert

Do you know all the 3-year rule details?

You may think that deciding whether you have a new or established patient is the easiest part of choosing an E/M code. But even this decision has a few hidden pitfalls. Avoid them with this guide to the ins and outs of new and established patients.

Look at Group to Determine Patient Status

Generally, you should consider a patient to be -established- if any physician in your group (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

A CMS transmittal (R731CP, change request 4032) reinforces the agency's -new/established- patient policy. You can see it on the Web at www.cms.hhs.gov/transmittals/downloads/R731CP.pdf.  The related MLN Matters article is at www.cms.hhs.gov/MLNMattersArticles/downloads/MM4032.pdf.

CMS- Definition of New Patient

A -new patient- is one who hasn't received an E/M or other face-to-face service -from the physician or physician group practice (same physician specialty) within the previous three years.- Diagnostic test interpretation without a face-to-face service does not change a new patient into an established one.

Established patient example: A patient comes to your office after being diagnosed with breast cancer. Although this is oncologist A's first time meeting the patient, oncologist B, in the same group practice, saw the patient two years ago (for the same or a different diagnosis). In this case, the patient is established.

Tip: Don't let different locations lead you astray. If your practice has multiple locations, and a physician in location -A- sees the patient in January but a physician in location -B- sees the patient the following December, the patient is still established. The need to create a new chart is inconsequential, Hammer says.

And remember, the patient's diagnosis doesn't matter when choosing patient status. If Oncologist A saw the patient for a primary malignancy, and Oncologist B, in the same group, later sees the patient for secondary malignancy treatment, use an established patient code for the visit to Oncologist B.

New patient example: A primary-care physician recommends that a 60-year-old female see an oncologist in your group. One of the physicians in your practice interpreted some test results for the same patient the previous year but provided no face-to-face service.

In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years, says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, Fla.

According to section 30.6.7 of the Medicare Claims Processing Manual, -An interpretation of a diagnostic test, reading an x-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.-

Look for the Different-Specialty Loophole

The new patient rule applies when physicians in the same practice are also of the same specialty.

In a nutshell: If your practice is big enough and covers enough specialties, two physicians may see a patient for completely different reasons. This could allow you to report a new patient visit even though two physicians in the same practice saw the same patient within a three-year period.

Example: An obstetrician in a large multiple-specialty practice sees a patient in 2004 for pregnancy-related services. In early 2006, the same patient sees the gynecologic oncologist -- who is a member of the same multi-specialty practice as the obstetrician -- for an office E/M service regarding ovarian cancer.

Because the obstetrician and gynecologic oncologist (who are of different specialties) saw the patient for completely unrelated problems, you may report the oncologist's initial visit with the patient using the new patient codes.

Caution: Rule May Differ for Subspecialty

The -separate-specialty- rule does not necessarily apply to subspecialties. For example, an oncologist who specializes in lung cancer and an oncologist who specializes in breast cancer still have the same specialty -- oncology. If the lung cancer specialist sees the patient, and later the breast cancer specialist in the same group sees the patient, report an established patient code for the visit with the breast cancer specialist.

Don't Waste Time Determining Status for Consult

The consult codes do not differentiate between new and established patients. Therefore, regardless of the patient's status, you should make your outpatient consult code choice from the 99241-99245 range (Office consultation for a new or established patient).
 
Remember: Always double-check that you-ve met consultation code requirements.