Pediatric Coding Alert

CPT Assistant says to maintain new patient as new for both services

When considering patient status on same-day preventive medicine services and problem-related visits, play the matching game: new-new and old-old.

Check Your Policy on OV After 99381-99384

CPT Assistant recently weighed in on this coding conundrum: A physician performs a new patient preventive medicine service (99381-99384) and then treats a significant problem. Should you code the office visit as new (99201-99205) or established (99212-99215)? New. The AMA "wants the codes to match," says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.

This ruling may contradict your current coding policies. "After performing a new patient preventive medicine service if I treated the patient for a separate and distinct additional problem, I billed an established patient office visit" (99212-99215 appended with modifier 25), Tuck says.

Other practices concur. "The physicians and I feel when the preventive is completed the patient is no longer a new patient," says Rebecca Lopez, CPC, at Bright Medical Associates in Whittier, Calif.

The rationale: The new patient codes contain extra value associated with evaluating a new patient, Tuck says. "I considered reporting two 'new' E/M services double-dipping."

Reserve 9921x Until You've Billed Patient

But for same-day E/M services involving a new patient, you should hold off on billing an established patient office visit on the initial day. This guidance was presented in the October 2006 CPT Assistant's Q&A: "Evaluation and Management" centers around the definition of a new patient. The CPT E/M service guidelines state:

"Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). 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."

Application: When an office visit follows a new patient preventive medicine service, no professional service has occurred. "You should consider the patient's status for the encounter, not for the individual portions," says David Glaser, an attorney with Fredrikson & Byron in Minneapolis. "CPT's instruction makes sense."

The office has not yet billed a face-to-face service as reported with a specific CPT code. CPT is indicating that you shouldn't code a patient as established until you've billed the patient for a service.

Once you bill 99381-99384 for a patient, consider the patient as established, unless three years elapse between visits. If an "acute visit (i.e., office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within three years, then it would be appropriate to report the established office or other outpatient visit code (i.e., 99211-99215, as appropriate)," according to the October 2006 CPT Assistant's Q&A.

Impact: Following these guidelines may trigger payment problems. The established patient charge is less than a new patient charge, Lopez says. So the new method could make payment for the encounter harder because  insurers will have to pay for two new visits.