Pediatric Coding Alert

Question: Our doctors see newborns in the hospital. Subsequently, the infants are assigned to one of our 65 pediatricians for office visits. Should I report a new patient office visit, or is the patient already established?

California Subscriber

Answer: "An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years," CPT 2002 states in the E/M guidelines on page 1. "Professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s)."

Therefore, if a pediatrician provides professional services to a newborn in the hospital, any pediatrician who has the same tax identification number and provides subsequent care must consider the patient an established patient and bill the appropriate established patient office visit code (99211-99215). The place of location is irrelevant to the new/established patient definition; new or established refers to the patient's relation to the pediatrician(s), not the patient's relation to the office.

Consider the following scenario. Pediatrician A evaluates a normal newborn in the hospital and reports 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records) and 99238 on the subsequent discharge day. Several weeks later, the baby has a rash and the mother brings her to the pediatrician's office for a checkup. The patient is now considered established, even though the baby has never been to the office. The pediatrician assigns the appropriate-level established patient office visit, such as 99212.

The same coding applies if Pediatrician A is unavailable and the infant is assigned to another pediatrician in the same practice. Even though Pediatrician B has never seen the infant, a physician who is in the same specialty and group has provided professional services within the past three years, which meets CPT's definition of an established patient.