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 apply to a new physician and any patients he sees prior to joining your practice. If the new physician has provided professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.

Example: A group practice maintains two offices on separate sides of town. A patient sees physician -A- for a complaint of knee pain at location -Y.- Six months later, the same patient sees physician -B,- in the same group practice and specialty, for a hip complaint at location -Z.-

In this case, the patient is established, even though the encounters took place at separate locations and involved separate physicians and different diagnoses.

Here's why: Because the physicians are of the same specialty and are billing under the same group number, the -three-year rule- applies. Had the physicians been of different specialties, or if they billed under different provider numbers, the second physician may have been able to report the patient as new, as long as she hadn't seen that patient within the previous 36 months.

Master Face-to-Face Matters

As in past years, the -new vs. established- guidelines apply only to face-to-face services. Therefore, if the surgeon (or another orthopedic surgeon 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 of the non-face-to-face service, you should still consider the patient to be new when selecting an E/M service code to bill.

Example: An orthopedic surgeon sees a patient for the first time for a radius fracture. Another physician in the same practice interpreted an x-ray for the patient when the patient went to the emergency department the previous year but provided no face-to-face service during the previous three years.

In this case, the physician providing the current service may still consider the patient to be new when selecting an initial E/M code because no physician within the group practice of the same specialty provided the patient with a face-to-face service within the past three years.

Different Specialty May Equal New Patient

When physicians of different specialties see the same patient within the same 36-month period, the usual -new vs. established- rules do not apply. Specifically, if a physician of a different specialty with the same tax ID within a multispecialty practice, or a subspecialist billing with a unique tax ID number, sees a patient for the first time, you may consider the patient to be new even if he has seen other physicians within the group practice during the previous three years.

If a subspecialist has a specialist distinction that is different from that of the physician who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient per the June 1999 CPT Assistant.

The difference: The subspecialist must be registered with a unique taxonomy code/number for his subspecialty, and the patient must not have seen any other physician who provides services of the same subspecialty for the practice within the last three years.

Example: An orthopedic surgeon sees a patient in 2005 for a total knee replacement. In early 2007, the samepatient sees a hand surgeon (a member of the same multispecialty practice) for an office E/M service regarding a ganglion cyst in the wrist.

If the hand surgeon is registered with the insurer under the hand surgery specialty (code 40 for Medicare) and not the orthopedic surgery specialty number (code 20 for Medicare), you can report the hand surgeon's initial visit with the patient assigning the new patient codes.