Pediatric Coding Alert

Question: A child stopped treatment with our office two years ago. May I report another new patient service? May a nurse practitioner provide the care?


New York Subscriber


Answer: No. When a patient returns to your office within two years, you should still use an established patient office visit code. In fact, you should continue to assign 99211-99215 until three years have elapsed since the last time you treated the patient in a face-to-face encounter, regardless of location. "A new patient is 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," states CPT's notes for new and established patients.

A nurse practitioner (NP) may provide the established patient service, but how you bill 99212-99215 depends on the insurer's incident-to policies. If the payer follows Medicare's requirements that the physician initiate treatment and see the patient on a regular basis, you should report the E/M code using the NP's identification number.

Although Medicare does not define the frequency at which the physician must see the patient, two years would definitely be beyond a feasible time that would demonstrate the doctor's continuing involvement in the patient's treatment.

Other insurers may have less stringent rules. In this case, you may bill the service under the pediatrician's number. Some payers may reduce payment for services billed under an NP's number and pay the code at 80 percent. Answers to You Be the Coder and Reader Questions provided by Barry Hersey, administrator at Pediatric Care of York PC in Pennsylvania; Peter D. Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University School of Medicine in Brockton, Mass; Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.