Orthopedic Coding Alert

Even if the patient has been to your office before, he might be new Proper billing for various E/M services (such as outpatient visits and rest home 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 flowchart, making a foolproof decision only a few questions away. Keep Applying the 3-Year Rule If the physician, or any physician of the same specialty billing under a common group number, has never seen a patient before, that patient is automatically categorized as new. And if the same physician (or, once again, any physician of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient new from a billing and coding standpoint.

Example: The orthopedic surgeon sees a patient in the office at the patient's request (in other words, the service is not a consult). Although the physician has seen the patient in the past, the last visit occurred more than four years before.

In this case, the patient is considered new rather than established. So, you would choose to bill a code from the new patient outpatient services category (99201-99205) rather than the established patient outpatient services category (99211-99215).

If the same physician or other physician of the same specialty billing under the same group number sees the patient at any time within a three-year timeframe, you must consider the patient to be established, even if the patient was seen at different locations.

Example: Suppose the patient sees the surgeon for knee pain in January and then again for hip pain in August. Since it's a new problem, can it count as a new patient?

-Being seen for a new problem does not qualify as a new patient visit,- says Jenny Harrison, coder at N-Orthopedics in Gaylord, Mich. -The patient has still been seen by the surgeon in the past three years. The fact that the patient is presenting with a new problem would be addressed in medical decision-making in helping to determine which level of service to bill.-

If your physician has billed the patient for a professional service in the past three years, you-ll bill any subsequent visits as established patient E/M codes (such as 99211-99215). Don't Factor in Location If the same physician or another physician of the same specialty is billing under the same group number and sees the patient at any time within a three-year timeframe, you must consider the patient to be established, even if the patient was seen at different locations, says Nancy Anderson, CPC, coder at OAA Orthopedic Specialists in Allentown, Pa.

Tip: These guidelines also [...]