Orthopedic Coding Alert

 Different locations, same physician? Use established patient codes When reporting many common E/M services, you must ask yourself two questions: First, is the patient new or established? And second, what are the documented levels of history, physical exam, and medical decision-making (MDM)? We-ve got some quick tips on how to use this information to select the correct E/M level every time. -3-Year Rule- Determines Patient Status Generally, you should consider a patient to be -established- if any physician in your group (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months, says Marvel J Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. A recent CMS transmittal (R731CP, change request 4032) re-enforces the agency's -new/established- patient policy.

For example: A patient complaining of lower-leg pain comes to your office. Although this is surgeon A's first time meeting the patient, surgeon B, in the same group practice, saw the patient two years ago for a similar complaint. In this case, the patient is established.
 
Don't let different locations lead you astray: If your practice has multiple locations, and a physician in location -A- sees the patient in January but a physician in location -B- sees the patient the following December, the patient is still established. The need to create a new chart is inconsequential, Hammer says.
 
Non-face-to-face encounters don't count: A primary-care physician recommends that a 60-year-old female see the orthopedic surgeon regarding stiffness in her shoulder. One of the physicians in your practice interpreted some x-ray results for the same patient the previous year but provided no face-to-face service.
 
In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years, says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, Fla.
 
According to section 30.6.7 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.-
 
Exceptions Could Occur for Different Specialties The new patient rule applies when physicians in the same practice are also of the same specialty, says Cindy 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.
 
In a nutshell: If your practice is big enough and covers enough specialties, two physicians may see a patient for completely different reasons, Parman says. This could allow you to report a [...]