Pediatric Coding Alert

Question: A patient came in for an evaluation and management (E/M) service on February 19, 2019. The patient previously received an E/M service from our practice on September 29, 2014. However, the patient also came in for allergy immunotherapy during the interim, and we documented 95165 several times, the most recent being June 13, 2018. Is the patient regarded as new or established to our practice?

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Answer: Both the CPT^®  and Centers for Medicare and Medicaid Services (CMS) definitions for established patients are the same: they are patients “who received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years,” per the CMS definition (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf).

The key phrase in this definition for your situation is “professional services,” which are not solely limited to E/M services. If your patient has received immunotherapy services from the same provider or another provider within the same specialty in your group practice, and you have documented 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)) for that patient within the three-year period, then your practice has administered a professional service to that patient within the established patient timeframe, and the patient would not be regarded as new.