Otolaryngology Coding Alert

Question: When a patient presents to the office for the first time after our physician discharges her from the hospital, can we report a new patient code if a different physician sees her? CPT says a new patient is one whom we have not seen in the past three years, but I have also heard that a new patient is one who requires a medical record to be established.

Arkansas Subscriber

Answer: CPT is very clear on this matter: "A new patient (99201-99205) 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. An established patient (99211-99215) is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years."

CPT does not base its new or established patient classification on whether your practice has established a medical record for any particular patient. The fact that your second physician created a medical record is irrelevant to the type of visit you should report. Because another otolaryngologist at your practice saw the patient within the last three years, you should report a code from the 99211-99215 series.