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 [...]