Pediatric Coding Alert

Question: One of our pediatricians just diagnosed a new patient with acute sinusitis and chronic rhinitis. The patient then moved to another pediatrician in our practice for further treatment for the problems. Is the patient, and are these conditions, now considered “new” to the second provider?

Louisiana Subscriber

Answer: Because the patient has already been seen by a provider in your practice, and because the patient has received initial care from one physician or qualified health care professional in your group and subsequent care from “another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the last three years,” per CPT^® guidelines you should regard the patient as established when seen by the second pediatrician.

As for the conditions, they can only be regarded as new when the patient first presents and the conditions are documented for the first time. Once the conditions have been entered into the patient’s record, they can no longer be considered new to any provider who practices the same specialty and subspecialty within the same practice as the initial provider who diagnosed the problems. If the patient’s sinusitis and rhinitis are, indeed, the same conditions originally diagnosed by the initial provider, or if the initial provider has used terms like persistent, chronic, or recurring — in other words, they are conditions that have not resolved — they would be regarded as established.

Consequently, since the patient is regarded as established, and as the patient has already been seen for the conditions by an initial provider who has, presumably, diagnosed the problem, documented the problem, and created a preliminary treatment plan, neither the patient nor the conditions would be considered new to the second provider.