Oncology & Hematology Coding Alert

Question: I have trouble keeping up with the little rules about whether a patient is new or established. Is there an easy way to figure this out?

Arizona Subscriber


Answer: The AMA, which publishes the CPT codes, offers these five questions to determine whether you should treat a patient as new or established for coding purposes.

1. Has the patient ever received any professional services from any physician in this group?

No: The patient is -new.- Yes: Go on to #2.


2. Has the patient received any professional service from a particular physician within the past three years, who is now reporting a service?

Yes: The patient is -established.- No: Go on to #3.


3. Has the patient received any professional service* from a physician in the group of the same specialty, within the past three years?

(* In the context of deciding between new and established, CPT defines a professional service as -those face-to-face services rendered by a physician and reported by a specific CPT code.-)

No: The patient is -new.- Yes: Go on to #4.
 

4. Has the patient received care from a physician of the exact same specialty within the past three years, or is a physician of a different subspecialty now providing care?

The providing physician is of the same specialty: The patient is -established.-

The providing physician is of a different subspecialty: Go on to #5.


5. Does the current providing physician have the same tax ID as the physician who provided a separate service within the past 36 months?

Yes: The patient is -established.-* No: The patient is -new.-

(*Medicare allows reporting of new patients for physicians in the same group but of different specialties, such as pulmonology and radiology.)


Note: You can also find a similar flowchart on page 2 of the -Evaluation and Management (E/M) Services Guidelines- portion of the CPT 2007: Professional Edition, published by the AMA.


The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders National Advisory Board.