Otolaryngology Coding Alert

Question: When may I code a new patient office visit for a patient whom our otolaryngologist treated in the emergency department in 2002? Could I use 99201-99205 if the otolaryngologist was covering for another physician? Also, suppose the hospital employed the otolaryngologist at the time of service, but since then he joined our practice. In this case, does CPT consider the encounter a new patient office visit?

New York Subscriber

Answer: You should consider the patient "new" when no otolaryngologist in your group has provided professional services to the patient within the past three years. You should submit the scenarios you describe using the following coding methods:

1. If your otolaryngologist treated the patient in the ED in 2002, you may report a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) starting three years from the service date, provided no ENT in your practice has billed a CPT code to the patient since the ED encounter.

For instance, your otolaryngologist treated the patient for a nosebleed (such as 30903, Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) in the ED on Oct. 1, 2002. Your three-physician otolaryngology practice next treats the patient on Oct. 2, 2005, when the patient presents complaining of allergy symptoms. You should bill a new patient visit for the encounter because three years have  elapsed since the last time your otolaryngologists treated the patient.

2. You should, however, report an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) if your otolaryngologist provided services to the patient while covering for another physician in the ED in the past three years. CPT specifies that "an established patient is one who has received professional services from the physician ... within the past three years." Even though the covering otolaryngologist may have billed the service under the original physician's group number, the otolaryngologist still provided professional services to the patient. Therefore, an auditor would probably consider the patient established.

3. You should also code your final example with 99212-99215. Your office didn't employ the otolaryngologist when he treated the patient in the ED, but the physician provided professional services to him. The patient-otolaryngologist relationship, not the physician's employer, determines the patient's status.

- You Be the Coder and Reader Questions provided by Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.; and Tara R. Ritter, appeals coordinator for American Physician Services, which serves multiple ENT, allergy, sinus, and head and neck practices in Atlanta.