Practice Management Alert

Specialty codes can clarify multispecialty confusion

You might think you can easily differentiate between new and established patients, but the choice is not always black and white - especially in the multispecialty world.
 
If a physician sees a patient who is already established under another physician in your practice, the medical specialties involved will determine whether you bill that patient visit as new or established. But before making that determination, you must understand the rules governing when to bill a new or established patient.
 
Brand-new patients: You should bill a new patient when the physician has "never before performed a face-to-face service on the patient" that you could report with a CPT code, says Shannon O. Smith, CRTT, CPC, consultant auditor with Doctors Management in Knoxville, Tenn. Phone calls, record reviews and other non-face-to-face services do not count as a new patient service.
 
Place doesn't matter: The location of patient encounters can vary, but the patient is not new if the physician rendered a face-to-face service in the past, says Terri Fischer, CPC, CMC, manager with LarsonAllen Health Care Group in St. Louis, Mo. For example, a new patient visit occurs in the hospital, and the same physician then treats the patient in the office. You would report that office visit as an established patient visit.
 
Time's up: You should also bill a new patient whenever the physician has not treated the patient "within a three-year time frame," Smith says.
 
Bill established: You should bill an established patient visit if the physician "has billed any type of face-to-face service on the patient" within the past three years that you could report with a CPT code, Smith says.
 In addition, if a new physician joins your practice, you should bill established patient visits for any patients who follow him to your practice. Although a patient may be new to your practice, she is not necessarily new to the treating physician.
 
Don't be fooled: Disagreements about this policy sometimes arise if the new physician can't obtain the patient's medical record from his last practice, Fischer says. If the physician has to reconstruct the record, some billers argue that the visit is a new patient. Not so, most carriers and coders agree. Know the Multiphysician Catch Suppose a patient sees one physician, and then on a later date sees a different physician within the same practice. You can only bill a new patient visit for the second encounter if the two physicians are of different specialties, and the patient sees the second physician for a specialty-specific reason, Fischer says.
 
For example, an internist (specialty code 11 - see section at right) may treat a patient with heart disease, and then recommend the patient continue his care [...]