Primary Care Coding Alert

Hint: The place of service(POS) won’t influence your choice.

The first step to consider in determining the appropriate evaluation and management (E/M) code for a service your FP provides is whether the patient is new or established. Your choice is made easy if you know how to apply the three-year rule.

Turn to CPT® for Guidance

A key factor in determining whether a patient is new or established is time, and you must decide whether your provider has seen the patient in the past, and if he has, how long ago.

Rule: CPT® clearly defines what qualifies as an established patient: “An established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

In CPT® parlance, “professional services” are “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT® code(s).”

Ask yourself, “Has the patient seen the provider in the past three years?” Here’s how to code based on your answer:

• Yes: If your provider has billed for a professional service in the past three years for a patient, you’ll report the visit using established patient E/M codes (such as 99211-99215), says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

No: If your provider has not seen the patient within the past three years and neither has another provider of the same specialty and subspecialty in the same group practice, you can report a new patient E/M code (such as 99201-99205), instructs Christy Shanley, CPC, CUC, administrator for the University of California, Irvine department of urology.

Don’t Assume a New Provider Means New Patient

If the patient has been seen before within the same practice, even though he switched doctors, he may be an established patient.

If you are in a group physician setting, under the same tax ID, you have to determine if the patient has seen any of the doctors (of the same specialty) and when before you can decide on a new or established patient code.

Example: An FP in your practice provides an initial inpatient service to a patient he’s never seen before. The patient has complaints of wheezing, and your FP diagnoses asthma and advises on the use of a metered dose inhaler. The patient is called back after a week for follow-up.

When the patient comes to your office for follow-up care one week later, he sees a different family physician, because the first FP that he saw is unavailable. You should report an established patient office visit for the physician’s in-office follow-up.

Even though the patient has never been to your office, and the second physician has never seen the patient, you should report an established patient code. The patient is an established patient because a physician in the same specialty and group provided professional services within the past three years.

Avoid Coding Based on Location

You should not use place of service (POS) for determining new versus established patient. Based on CPT®’s established patient definition, new versus established refers to the patient’s relationship to the physician, not his relationship to the practice or its location.

“POS is irrelevant,” Shanley says. Even if your physician saw a patient in the emergency room rather than in your office, the next time your provider or one of his associates in the same specialty sees that patient he is an established patient.

Guideline: If a physician provides professional services to a patient in the hospital, all of his partners (physicians) in the same specialty, with or without the same tax identification number, who provide subsequent office or outpatient care must consider the patient an established patient and bill the appropriate established patient office visit code (99211-99215).

Pay Attention When Physicians Change Practices

All of these new versus established patient rules also apply to a new physician in your practice. If the new provider 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.

If a patient’s doctor leaves the practice but the patient starts seeing another doctor within that practice, the patient is still established because the physicians (assuming they’re in the same specialty) use the same tax ID, Boone says. And if that patient follows the doctor to a new location, s/he is still an established patient. To determine new or established patient payments, insurers will look at the provider’s National Provider Identifier (NPI), not where the service was provided.