Pediatric Coding Alert

Question: A provider insurance representative recommended at an in-house seminar that when our pediatricians see new patients in the hospital, we can still bill them as new patients in the office as well. But I've been considering patients whom a physician treats in the office after initially examining the patient in the hospital as established patients. Who is correct?


New York Subscriber

Answer: You are correct. CPT defines a new patient as "one who has not 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."

Strategy: Show the insurance representative CPT's new and established patient definition under the heading "Definitions of Commonly Used Terms" in Evaluation and Managements Services Guidelines. The representative may be unfamiliar with in-office coding that follows this rule.

A patient's status doesn't affect hospital care coding. For instance, you report initial hospital care with 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) and subsequent hospital care as 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...), regardless of whether the patient is new or established.

But if one of your pediatricians treats a patient in the hospital and later (within three years) treats the patient in the office, you must code the encounter as an established patient E/M service, such as 99212-99215 (Office visit for the evaluation and management of an established patient ...).