Pediatric Coding Alert

Question: Our practice performed a test on a patient another doctor referred to us. Our physician was not present for the procedure; a technician administered the test. Should I consider this patient an established patient when she returns for additional care?

Mississippi Subscriber

Answer: No, you should consider the patient "new" until a face-to-face encounter with your physician occurs. If the primary physician (or another physician billing under the same group number) provided a non-face-to-face service for a patient and then provided a face-to-face service within three years, you should still consider the patient to be "new" when selecting an E/M service code for the face-to-face service.

According to AMA guidelines, there are additional factors to consider as well:

The three-year rule is a well-established rule for "new" versus "established" patients. That is, if any physician within a given practice has a face-to-face visit with a patient within a 36-month period, that patient is considered "established."

If visits occur outside of that time period, the patient would return to new patient status.

If two physicians are of the same specialty and billing under the same group number, the three-year rule applies. If they work under different specialties or bill under different provider numbers, the second specialist may be able to report the patient as "new," as long as she hadn't seen that patient within the previous 36 months.