Otolaryngology Coding Alert

Question: The otolaryngologist sees a patient in the hospital and performs a tracheostomy (31600, Tracheostomy, planned [separate procedure]). A month later, the patient sees the otolaryngologist in the office for follow-up. The patient was not a patient of ours prior to the procedure at the hospital. Should we bill a new or established patient visit?

Oregon Subscriber

Answer: The encounter should be reported as an established patient visit (99212-99215). By performing a procedure, the otolaryngologist had a face-to-face encounter with the patient. This qualifies the patient as established, according to the introduction to the evaluation and management section of the CPT manual, which states:

"Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years."

In 2001, CPT created a small exemption for physicians who read tests, such as electrocardiograms, at the hospital but do not see the patient face-to-face. In this case, the tracheostomy qualifies as a professional service and, therefore, any subsequent encounters are considered established patient visits unless the otolaryngologist (and all members of his or her practice) does not see the patient for a minimum of three years.