Otolaryngology Coding Alert

Question: We are aware of the new patient rules for office/ outpatient evaluation and management (E/M) visits, but this situation is a new one for me: Our otolaryngologist was a solo practitioner who joined our practice and brought most of his existing patients with him. Since joining our practice, he has billed all of those patients with new patient codes, even if he saw them within the last three years at his previous practice. Our office is split on whether this is appropriate. Can you help?

Texas Subscriber

Answer: The physician should not be reporting new patient codes if he saw the patients within the last three years, even if they were seen at a different practice.

You’ll find that CPT^® rules don’t mention anything about separate practices. Instead, the guidelines state, “A new patient is one who has not received any professional services from the physician/ qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

To isolate the important part of this, look at the segment that reads that the patient “has not received any professional services from the physician/qualified health care professional … within the past three years.” It says “or” before the reference to the same group practice, not “and,” which means that the group practice does not have to be the same for the rule to apply. The doctor in your office should be reporting these patients using the established patient codes.