Pediatric Coding Alert

Is your patient new or established? We help break down the answers.

To accurately report an outpatient evaluation and management (E/M) service (99201-99215), you start your code selection by determining whether the patient is new or established – base your code choices by using the three-year rule to determine the patient’s status. But in many cases, that can be hard to determine.

CPT rule: The chief factor in determining whether a patient is new or established is time. You must decide whether you have seen the patient in the past, and if you have, how long ago. CPT® clearly defines what qualifies as an established patient: “An established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

In CPT® parlance, “professional services” are “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s)” (emphasis added).

Ask yourself, “Has the patient seen the provider in the past three years?” Here’s how to code based on your answer:

• Yes: If you have billed for a professional service in the past three years for a patient, you’ll report the visit using established patient E/M codes (such as 99211-99215).
• No: If you have not seen the patient within the past three years and neither has another provider of the same specialty and subspecialty in your group, you can report a new patient E/M code (such as 99201-99205).

However, even though the three year rule may seem clear-cut, several subscribers have submitted related questions to Pediatric Coding Alert. We’ve compiled the three most common questions on this topic and provided answers for your guidance.

Keep POS Out of the Equation

Question 1: A hospitalist asked my pediatrician to see a premature newborn who failed a hospital hearing screening. The pediatrician saw the infant a week later in the office for an initial visit. The pediatrician documented a detailed history, a detailed examination, and low-complexity medical decision-making at the hospital encounter and the office visit. Should I code the E/M services with 99253 and 99203?

Answer 1: You should not use place of service (POS) as an indication of new versus established patient. Based on CPT®’s established patient definition, new versus established refers to the patient’s relationship to the physician, not his relationship to the practice or its location.

Because POS is irrelevant to this topic, even if the physician saw a patient in the nursery or emergency room rather than in your office, the next time the provider or one of his associates in the same specialty sees that patient he is an established patient.

Even though this infant is new to the office, you should report an established patient office visit (99211-99215), not a new patient E/M service (99201-99205, Office or other outpatient visit for the E/M of a new patient ...). Because the pediatrician had a face-to-face visit with the infant in the hospital, the patient became an established patient for subsequent E/M encounters.

“Quick Look” Constitutes A Service

Question 2: Our pediatrician saw a newborn as a quick assessment within a few days of birth at no charge. The mother returned with the baby at two weeks for a complete exam. Should this be billed as an E/M service, and if so, should it be established or new?

Answer: When this visit is a follow-up to an identified problem such as jaundice, infrequent stools, or infrequent feedings, and the physician, nurse practitioner, or physician assistant provides the service, an established office visit (eg, 99212-99215) and problem-specific diagnosis codes should be reported. The patient will be considered “established” because you already saw the patient during a face-to-face encounter within the last three years, which constitutes an established patient under the CPT guidelines. Again, the guidelines are interpreted literally.

New Problems Don’t Equate to New Patients

Question: Our pediatrician saw a patient six months ago for a consultation, and sent the patient back to his regular provider for further treatment. The same patient was recently referred back to us for a different condition. Should we bill that patient as new, since he’s coming back for a different reason?

Answer: This patient should be considered “established” at your practice.

If you see a patient face-to-face any time within a 36- month period, that patient is considered established, regardless of the reasons for the visits.

Caution: The rules change 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.