Practice Management Alert

Even if the patient has been to your office before, he might be new

Proper billing for various E/M services (such as outpatient visits and rest home services, for example) rests on determining whether a patient is -new- or -established,- as defined by AMA guidelines. To make the -new vs. established- decision easier, CPT 2007 includes a helpful flowchart -- making a foolproof decision only a few questions away.

Keep Applying the 3-Year Rule

If the physician, or any physician of the same specialty billing under a common group number, has never seen a patient before, that patient is automatically categorized as -new.- And if the same physician (or, once again, any physician of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient -new- from a billing and coding standpoint.

Example: The physician sees a patient in the office at the patient's request (in other words, the service is not a consult). Although the physician has seen the patient in the past, the last visit occurred more than four years before.

In this case, the patient is considered new rather than established. So, you would choose to bill a code from the new patient outpatient services category (99201-99205) rather than the established patient outpatient services category (99211-99215).

If the same physician or other physician of the same specialty billing under the same group number sees the patient at any time within a three-year timeframe, you must consider the patient to be -established,- even if the patient was seen at different locations.

If your physician has billed the patient for a professional service in the past three years, you-ll bill any subsequent visits as established patient E/M codes (such as 99211-99215), says Beth Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants in Winston-Salem, N.C.

Don't Factor in Location

If the same physician or another physician of the same specialty is billing under the same group number and sees the patient at any time within a three-year timeframe, you must consider the patient to be -established,- even if the patient was seen at different locations, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Tip: These guidelines also apply to a new physician and any patients he sees prior to joining your practice. If the new physician has provided professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.

Example: A group practice maintains two offices on separate sides of town. A patient sees physician -A- for a complaint of urinary pain at location -Y.- Six months later, the same patient sees physician -B,- in the same group practice and specialty, for a new complaint at location -Z.-

In this case, the patient is established -- even though the encounters took place at separate locations and involved separate physicians.

Here's why: Because the physicians are of the same specialty and are billing under the same group number, the -three-year rule- applies. Had the physicians been of different specialties -- or if they billed under different provider numbers -- the second physician may have been able to report the patient as -new,- as long as she hadn't seen that patient within the previous 36 months.

Master Face-to-Face Matters

As in past years, the -new vs. established- guidelines apply only to face-to-face services. Therefore, if a physician (or another physician billing under the same group number) provided a non-face-to-face service for a patient, and then provided a face-to-face service within three years of the non-face-to-face service, you should still consider the patient to be -new- when selecting an E/M service code to bill.

Example: A cardiologist sees a patient for the first time for a new complaint. Another physician in the same practice interpreted an EKG for the patient when the patient went to the emergency room the previous year but provided no face-to-face service during the previous three years.

In this case, the physician providing the current service may still consider the patient to be new when selecting an initial E/M code because no physician within the group practice of the same specialty provided the patient with a face-to-face service within the past three years.

Different Specialty May Equal New Patient

When physicians of different specialties see the same patient within the same 36-month period, the usual -new vs. established- rules do not apply. Specifically, if a physician of a different specialty with the same tax ID within a multispecialty practice -- or a subspecialist billing with a unique tax I.D. number -- sees a patient for the first time, you may consider the patient to be -new- even if he has seen other physicians within the group practice during the previous three years.
 
If a subspecialist has a specialist distinction that is different from that of the physician who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient per the June 1999 CPT Assistant, says Stacie L. Buck, RHIA, LHRM, president of Health Information Management Associates Inc. in North Palm Beach, Fla.

The difference: The subspecialist must be registered with a unique taxonomy code/number for his subspecialty, and the patient must not have seen any other physician who provides services of the same subspecialty for the practice within the last three years.

Example: An internist in a multiple-specialty practice sees a patient in 2005 for diabetes treatments. In early 2007, the same patient sees the general surgeon (a member of the same multispecialty practice) for an office E/M service regarding a new complaint.

Because the internist and general surgeon (who are of different specialties) saw the patient for completely unrelated problems (this is key), you may report the surgeon's initial visit with the patient assigning the new patient codes.