Pediatric Coding Alert

Question: Is a patient a new or an established patient when a physician in one specialty transfers the patient to a physician in a different specialty, and both physicians are under the same tax identification number?


Montana Subscriber

Answer: You should count the individual as a new patient. The CPT definitions for new and established patients refer to services that physicians in the same specialty render.

When a physician transfers a patient within the group practice to a physician in another specialty, you should consider the patient a new patient.

Example: A family physician (FP) refers a young child who has missed several development and language milestones (such as 783.42, Delayed milestones) to a developmental pediatrician in the same primary-care practice. The pediatrician who has never rendered services to the patient treats him in the office.

You should report a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...). Even though the family physician and the pediatrician are in the same group practice, they are in different specialties, so the patient is new to the pediatrician.

Watch out: Non-boarded sub-specialist patient referrals are considered established, unless the individual has a different tax identification number.

Example: A pediatrician refers a school-age patient who is having school related problems (for instance V62.3, Other psychosocial circumstances; educational circumstances) to his partner who has additional training in school development, but is not developmental-behavior sub board-certified.

Because the developmental behavior-concentrated pediatrician is not in a different board-certified subspecialty, but instead specializes in this area, you should consider the patient an established patient. So you would report an office visit with 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).