Pediatric Coding Alert

Question: When my pediatrician covers for another local private-practice pediatrician, I code the office visits as established patient E/M services. If, a couple of weeks later, a patient decides to switch to my pediatrician as her primary physician, should I report a new or established patient office visit? This visit will require all necessary new patient paperwork.

Tennessee Subscriber

Answer: As a covering physician, your pediatrician temporarily takes the place of the patient's regular pediatrician, so your pediatrician technically didn't provide any services to the patient. Therefore, you should use a new patient office visit code (99201-99205; Office visit for the evaluation and management of a new patient ...).

In reciprocal arrangements, you report the E/M service under the regular physician's name and classify the encounter as the normal pediatrician would have if he or she had been available. For instance, when your pediatrician covers for a level-three established patient office visit, you report 99213-Q5 (Office visit for the evaluation and management of an established patient ...; Service furnished by a substitute physician under a reciprocal billing arrangement [Note: This is a HCPCS level-II modifier]) even though your pediatrician never previously saw the patient to establish a relationship. The visit doesn't require a new patient history, paperwork or all three E/M components: history, examination and medical decision-making.

But when the same patient comes to your office to establish a relationship, you have no paperwork regarding the patient. And your records don't indicate that your pediatrician provided any professional services to the patient in the past three years. Because the visit meets CPT's definition of a new patient, you should assign the appropriate-level new patient office visit code (99201-99205) for the patient's first visit to your pediatrician.