Orthopedic Coding Alert

Question: When my orthopedist covers for another local private-practice physician, I code the office visits as established patient E/M services. If, a couple of weeks later, a patient decides to switch to my orthopedist permanently, should I report a new or an established patient office visit? This visit will require all necessary new patient paperwork.

Tennessee Subscriber

Answer: You should report a new patient office visit code (99201-99205) for your orthopedist's E/M service.
 
As a covering physician, your orthopedist temporarily replaces the patient's regular physician, and the regular physician reports the service to the insurer, so by Medicare standards your physician technically doesn't provide any services to the patient. Therefore, you should use a new patient office visit code (99201-99205; Office visit for the evaluation and management of a new patient ...) when your physician covers for another.
 
When your physician operates under a reciprocal arrangement with the physician you temporarily replaced, you report the E/M service under the regular physician's name and classify the encounter as the normal orthopedist would have if he had been available. For instance, when your physician covers for a level-three established patient office visit, you report 99213-Q5 (Office visit for the evaluation and management of an established patient ...; Service furnished by a substitute physician under a reciprocal billing arrangement [Note: This is a HCPCS Level II modifier]) even though your orthopedist never previously saw the patient to establish a relationship. The visit doesn't require a new patient history, paperwork or all three E/M components: history, examination and medical decision-making.
 
But when the same patient comes to your office to establish a relationship, you have no paperwork regarding
the patient, and your records don't indicate that your physician provided any professional services to the patient in the past three years. Because the visit meets CPT's definition of a new patient, you should assign the appropriate-level new patient office visit code.
 
Note: Reciprocal billing rules apply to Medicare payers only. Private payers may publish their own reporting guidelines on this topic.