Practice Management Alert

Question: We saw a patient for pain injections earlier in the year and he is now coming in for an office visit for evaluation. Do I bill a new patient code since patient was never seen for an office visit before or do I use an established patient code since we have done injections on the patient?

Codify Member

Answer: Use an established patient code. CPT's rule on established versus new patient depends only on whether the physician (or a same specialty partner in the same group) has provided face-toface services or procedures to the patient in the past three years.

How it works: CPT clearly defines what qualifies as an established patient: "An established patient is one who received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." Ask yourself, "Has the patient seen the physician in the past three years?" Here's the best way to code based on your answer:

Yes: If your physician has billed for a professional service in the past three years for a patient, you'll report any subsequent visits using established patient E/M codes (such as 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

No: If your physician has not seen the patient within the past three years, you can report a new patient E/M code

Note: Non face-to-face services such as reviewing lab reports and evaluating x-rays do not count toward the rule, but a faceto- face procedure such as a pain injection does count.

Remember: You should not use the place of service (POS) as an indication of whether you are working with a new patient versus an established one. Based on CPT's established patient definition, new versus established refers only to the patient's relationship to the physician, not his relationship to the practice or its location.