Oncology & Hematology Coding Alert

The three-year rule isn’t the only thing you need to know.

Evaluation and management (E/M) service coding may have changed a lot in the last few years, but one thing has remained the same: The CPT^® guidelines for determining whether a patient is new or established to your practice.

But if all you know about this distinction is the rule that “an established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years” per those same CPT^® guidelines, then you really don’t know the full picture. That’s why we’ve answered four of your frequently asked questions about the classification to help you, and your practice, code E/M services accurately, receive the correct amount of reimbursement, and stay compliant.

Know What Lies Behind the Rule

Question: Why is the distinction important?

First, “misidentifying a new patient as established poses a billing risk, as the reimbursement is higher for a new patient at the same level of service,” due to the extra work typically involved in taking the patient’s history and diagnosing new conditions, explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. For example, the 2023 Medicare national nonfacility fee for 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) is $90.82, whereas the fee for the corresponding new patient E/M service, 99203, is $112.84, a difference of $22.02.

But the second reason your office needs to make the distinction correctly may be more important. “You could also be facing compliance issues,” Falbo warns.

Know the Difference Between TIN and Taxonomy Codes

Question: If a patient sees two providers with different specialties in the same practice, is the patient automatically established after the first E/M?

Often, different providers practicing in different specialties may be billing under the same group taxpayer identification number (TIN), making it seem like the billing is the same regardless of provider specialty. However, TINs are not the deciding factor to determine specialty and subspecialty differences. Providers may also have different specialty and/or taxonomy codes supporting the difference.

As an example, suppose a surgical oncologist provides services to a patient, then, within the three-year time period, the patient returns to receive services from a medical oncologist. Both providers bill under the same practice TIN, but they have different specialty and taxonomy codes.

In this case, the patient’s first appointment with the surgical oncologist would be coded as a new patient encounter, assuming the patient had not seen that provider or another surgical oncology physician in the group practice within the three years prior to that first appointment. But the patient’s first appointment with the medical oncologist would also be coded as a new patient encounter, given that the medical oncologist’s specialty and taxonomy code should be different from the surgical oncologist’s if properly credentialed. Or, to use language from the CPT^® guidelines, though they belong to the same group practice, they are not practicing within the exact same specialty and subspecialty.

Know the Medicare Non-Face-to-Face Rule

Question: If a patient receives non-face-to-face services, does that make them established to the practice?

In this case, according to Medicare, the answer is no. Here’s why.

Suppose an oncologist in a specific practice interprets a patient’s blood test results and sends the report to the patient’s primary care physician (PCP). Then that same patient returns within three years to see another oncologist in that same practice for a suspicious lump in the breast.

In this situation, the patient did not receive face-to-face services from the first oncologist. According to section 30.6.7.A 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” (www.cms. gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ clm104c12.pdf).