Pediatric Coding Alert

Question: An intensive care physician asked my pediatrician to see a premature newborn who was having respiratory problems in the hospital. The pediatrician subsequently saw the infant three weeks later in the office for an initial office visit. The pediatrician documented a detailed history, a detailed examination, and low-complexity medical decision-making during the office visit. Should I report 99203?

Answer: That would be the correct code if the infant were a new patient, but in this case, you treated an established patient.

Why? Once your physician has provided a face-to-face service for the patient, the child is considered an established patient. You should instead report the office visit with 99214 (Office or other outpatient visit for the E/M of an established patient ...).

Even though the 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 ...). CPT^® defines a new patient as one who hasn’t 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. Because the pediatrician had a face-to-face visit with the infant at the hospital, the patient became an established patient for subsequent E/M encounters.

And the office visit’s documentation qualifies as a level-four established patient office visit (99214) instead of a level-three new patient E/M (99203). Unlike a new patient office visit, which requires all three key components, an established patient office visit only requires two. Therefore, you may report the E/M service with 99214 assuming the medical necessity and documentation of the problem support the level four visit.