Practice Management Alert

Question: My provider said that if an established patient comes in for workers- comp, we bill it as a new patient visit for the first workers- comp visit. That doesn't make sense to me. Who is right?

Michigan Subscriber

Answer: You are correct. You need to explain to your provider that the type of insurance coverage for a visit, including workers- compensation, does not affect whether you should bill a patient as new or established.

An established patient -- one whom your provider or another provider in the same practice and same specialty has seen within the past three years -- is an established patient, regardless of insurance. In this case, if the patient is already established with your practice, you should bill the correct-level E/M service (99212-99215, Office or other outpatient visit for the E/M of an established patient ...) under the workers- compensation insurance.

Keep in mind: You can bill a prolonged service code (+99354, Prolonged physician service in the office or other outpatient setting ... and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) in addition to the office visit code if the physician has to spend additional time evaluating the new complaint, filling out workers- compensation paperwork (see 99455-99456), and such. Make sure the visit meets the time requirements and that the provider clearly documented the start and end times in the patient's medical record.