Pediatric Coding Alert

Question: If one of our pediatricians referred a patient to one of our nurse practitioners for primary care, will the patient be considered new, as he is seeing the NP for the first time, or established, as he has already been seen by our pediatrician?

Answer:  As per CPT® guidelines, “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” Otherwise, the patient is considered “established.”

So, you can only bill the patient as a “new patient” if the patient is being seen by your nurse practitioner (NP) for the first time and no other physician or qualified health care professional of the exact same specialty and subspecialty in your practice has seen the patient in the past three years. If the NP’s specialty is pediatrics, then in the case scenario that you have described, the patient should probably be considered “established,” because he has already visited your pediatrician and been referred to your NP for other services. That is, if your pediatrician and NP are considered the exact same specialty and subspecialty, you cannot report the patient as a “new patient” even though he is seeing your NP for the first time.