Podiatry Coding & Billing Alert

Hint: Report 99211 for established patients only.

Although the “three-year” rule is helpful, it is not the only information you need to be aware of when determining whether your patients are new or established. For example, you must also know what kinds of services your patients have already received before making this distinction.

Read on understand if patients are new or established in your podiatry practice.

Explore Different Nuances of 3-Year Rule

A close reading of the CPT^® guidelines reveals much more than the simple definition that a new patient is one that has not received services from your practice in three years prior to seeing your provider. CPT^® also requires that:

1. The services need to be professional. “‘Professional’ here means services following the CPT^® definition of being performed by a physician or other qualified healthcare professional [QHP] and being reported by an E/M code,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

2. The services need to be face-to-face. “This is also key, as the Centers for Medicare and Medicaid Services [CMS] has determined that services such as EKGs, diagnostic tests, or X-ray interpretations do not affect a patient’s status unless they are accompanied by an E/M or other face-to-face service,” Falbo continues.

3. The services need to be in the same specialty or subspecialty. This part of the definition can be significant for large practices that may employ subspecialists, as patients that may be regarded as established in one specialty may be classified as new when they are seen for the first time by a specialist in a different field.

Can We Use 99211 for a New Patient?

This is a very common myth when the issue of a patient’s status comes up. Technically, as 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services) does not require the presence of a physician and requires no history, it appears as if you could use the code for a new patient.

However, this is a myth for two very good reasons.

First, “CPT^® describes the 99211 service as being for an established patient, so it cannot be used for a new patient,” Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana Holle explains.

“Use of 99211 is strictly for established patients — never a new patient since there must be a plan of care with the plan documenting a brief follow-up E/M encounter,” agrees Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J.

Secondly, 99211 can only be for established patients because the service is performed incident-to, meaning that any service, “even one as simple as a weight check, has to be reviewed by the provider. But without any type of history it will be difficult for the provider to give any advice,” Holle recommends. Simply put, “If a patient comes in, it is best practice to have the patient seen by the provider who will initiate a care plan,” Holle concludes.

Shannon O. DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, partner at DoctorsManagement, and president of NAMAS in Melbourne, Fla., echoes the truth that 99211 must only be used for established patients.

“99211 is only for established patient’s because it is technically performed incident-to, meaning the ancillary staff nurse will be using the supervising provider’s billing information to get the practice paid for the work,” DeConda says. “In order to meet the guidelines associated with incident-to, the patient must have a plan of care that has already been created by a supervising provider. The nurse would be providing following services directly indicated and/or appropriate to the plan of care.”

Why Should New Versus Established Matter to You?

Defining a patient as new or established is significant for two more reasons.

First, misidentifying a new patient as established “poses a billing risk, as the reimbursement is higher for a new patient,” due to the extra work involved in taking the patient’s history and diagnosing new conditions, Falbo explains.

But just as important, if you fail to assign new or established status to a patient correctly, “you could be facing compliance issues,” Falbo warns.

“As the criteria for the sick visits are distinctly different between new and established, the coder could give the wrong information to the payer,” Holle agrees. For example, while new and established level-four visits both require the provider to document moderate-complexity decision making (MDM), new visits require you to document three components, including a comprehensive history and exam, while you only have to document two elements, which can include a lower-level detailed history and detailed exam, for established visits.