Part B Insider (Multispecialty) Coding Alert

Question: I have a patient who was seen over three years ago. But, from 2009 through 2011 we renewed his allergy serum to be administered by his PCP.

Is he a new patient since he was not actually seen within three years? Or, is the fact he received his serum a "visit" so to speak and I can now only bill an established patient?

South Carolina Subscriber

Answer: As long as your physician (or any physician in the same specialty in the practice) did not see that patient, you should bill this patient as a new patient using the appropriate code in the 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components ...) range rather than an established patient code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...).

Here's why: CPT clearly defines what qualifies as an established patient: "An established patient is one who 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." Non-face-to-face services such as reviewing lab reports, evaluating x-rays, or refilling meds do not count toward the new versus established patient rule. Note that CPT and CMS guidelines do not vary on the definition of a new or established patient.

The rule: If your provider sees a patient any time within a 36-month period, that patient is considered established, regardless of the reasons for the visits. This is the AMA's "three-year rule." You should go by this rule even if a different physician in your practice sees the patient, as long as it's within the 36 months and as long as all the physicians in your group bill under the same group number.

Official wording: The 2012 CPT manual specifically mentions face-to-face services: "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 exact same specialty and subspecialty who belongs to the same group practice within the past three years."

Distinction: The rules change a bit if you are operating in a multi-specialty practice. If a physician of a different specialty sees a patient for the first time, you may consider the patient to be new even if he has seen other physicians in other specialties within the group practice during the previous three years.