Eli's Rehab Report

Question: When my physiatrist covers for another local private-practice rehab physician, I code the office visits as established patient E/M services. If, a couple of weeks later, a patient decides to switch to my physiatrist permanently, should I report a new or an established patient office visit? This visit will require all necessary new patient paperwork.

Tennessee Subscriber

Answer: You should report a new patient office visit code (99201-99205, Office or other outpatient visit for the E/M of a new patient ...).

As a covering physician, your physiatrist temporarily replaces the patient's regular rehab physician, and the regular physician reports the service to the insurer, so by Medicare standards, your physician technically doesn't provide any services to the patient.

Therefore, you should use a new patient office visit code (99201-99205) when your physiatrist covers for the other physician.

When your physician operates under a reciprocal arrangement with the physician whom you temporarily replaced, you report the E/M service under the regular physician's name and classify the encounter as the normal physiatrist would have if he or she had been available.

For instance, when your physician covers for a level-three established patient office visit, you report 99213-Q5 (Office visit for the evaluation and management of an established patient ...; Service furnished by a substitute physician under a reciprocal billing arrangement [Note: This is a HCPCS level-II modifier]) even though your physiatrist never previously saw the patient to establish a relationship. The visit in question would not require a new patient history, the necessary paperwork or all three E/M components of history, examination and medical decision-making.

But when the same patient comes to your office to establish a relationship, you have no paperwork regarding the patient, and your records don't indicate that your physician provided any professional services to the patient in the past three years.

Because the visit meets CPT's definition of a new patient, you should assign the appropriate-level new patient office visit code (99201-99205) for the patient's first visit to your physician.