Otolaryngology Coding Alert

Question: A patient shows up at our office complaining of an earache. An ENT at our branch office across town saw her seven months ago. Do I code her as a new patient?

Idaho Subscriber

Answer: If the same physician or other physician of the same specialty billing under the same group number sees the patient at any time within a three-year timeframe, you must consider the patient established, even if the patient was seen at different locations by different ENTs.

In this case, the patient is established, even though the encounters took place at separate locations and involved separate otolaryngologists.

Here's why: Because the ENTs are of the same specialty and billing under the same group number, the three-year rule applies. Had the surgeons been of different specialties-- or if they billed under different provider numbers -- the second surgeon may have been able to report the patient as new, as long as she hadn't seen that patient within the previous 36 months.