Primary Care Coding Alert

Although CPT defines new and established patients under Definitions of Commonly Used Terms, there are some instances when using one instead of the other is not so evidentnewborns, different doctors, new practices and emergency room visits can confuse coders. CPT states, A new patient is one who has not 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. On the other hand, An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. In the instance where a physician is on call for or covering for another physician, the patients encounter will be classified as it would have been by the physician who is not available.

Kent Moore, manager of healthcare financing and delivery systems for the American Academy of Family Physicians, emphasizes the key points to consider when determining if a patient is new or established: Have you seen him or her before? How long has it been since you have seen the patient? Has the patient been seen by another physician in your practice? Is that physician of the same specialty or of a different specialty?

Several scenarios help clarify some potentially confusing situations when determining if a patient is new or established.

Scenario #1: The family physician (FP) sees a newborn in the hospital and would code 99431 (history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records). Several weeks later, the baby has a bad cold and the mother brings her to the FPs office for a checkup. Now the patient is considered established, says Jean Ryan, CPC, billing compliance analyst for MeritCare Health System in Fargo, N.D., even though the baby has never been to the office before this visit. Thus, the FP would code 99212 (office or outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; and straightforward medical decision-making).

Scenario #2: A 50-year-old established female patient makes an appointment to see her FP but when she arrives for the visit, the physician is delivering a baby. Instead, she sees another FP in the group practice. Even though its a different doctor, its still the same specialty in the same practice, so she is considered an established patient. The codes 99212-99215 (office or outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: ranging from a problem focused to a comprehensive history, a problem focused to a comprehensive examination and straightforward medical decision-making to one of high complexity) would be used.

On the other hand, if she decides to see an ob/gyn in the same practice as her FP (whom she has been seeing for 10 years), she is now considered a new patient with the ob/gyn. The codes 99201-99205 (office or outpatient visit for the evaluation and management of a new patient, which requires these three key components: ranging from a problem focused to a comprehensive history, a problem focused to a comprehensive examination and straightforward decision-making to one of high complexity) now apply. Its a different doctor in a different specialty, Ryan points out.

Scenario #3: An FP changes group practices and one of his established patients comes to see him at his new clinic. The patient is still an established patient even if the office is new to him or her, Ryan explains.

The patient is considered established because the provider rendered a professional service to the patient in the past three years, says Jean Stoner, CPC, manager of coding operations for CodeRyte, a coding software company in Bethesda, Md. The CPT definition of a new patient does not distinguish between new or old practice. If the provider has rendered a service in the past three years, the patient is established regardless of the physicians new affiliation.

The gut reaction is to consider the patient new since it is his or her first visit to the new office, but professional services have been rendered in the past three years, says Moore.

Understand Professional Service

Stoner says it is important to understand what constitutes a professional service. It seems to mean something different for CPT than for Medicare, she says. She points out that the American Medical Association (AMA) defines a professional service as any medical service rendered by the provider, which can include prescription refill, an EKG interpretation or an emergency room visit. The service does not necessarily have to be a billable service (e.g., a prescription refill) to be considered a professional service.

For example, Stoner says, if an FP calls in a prescription for a new patient who hasnt yet seen the physician, when the patient finally does come into the office for the first visit, the patient must be considered established according to CPT guidelines. But some Medicare carriers are making a distinction that CPT doesnt. They are specifying that a professional service is an evaluation and management (E/M) service (visit, consult), and other services such as test interpretations, procedures or prescription refills are not.

If your physician provided an EKG interpretation and then six months later the patient shows up at the office as a first-time patient, the new visit codes could be used, Stoner continues. Bottom line, check with your Medicare carrier to find out if they have a definition of new vs. established patient in writing. If not, then follow the CPT guidelines.

Scenario #4: A 35-year-old man in a small, rural town slices open his finger and rushes to the emergency room where he is seen by an FP, who has also assumed the role of emergency physician. The FP would code 99281-99285 (emergency department visit for the evaluation and management of a patient, which requires these three components: ranging from a problem focused to a comprehensive history, a problem focused to a comprehensive examination and straightforward medical decision making to one of high complexity). The man later returns to see the same FP at his or her office to ensure that the wound is healing properly. Now the man is considered an established patient. Ryan reminds FPs that there is no distinction between new and established patients in the emergency department.

E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department, CPT says. Doctors often try to misconstrue that distinction, Ryan says.

Again, Stoner says, if the provider rendered a service to this patient in the past three years, the patient is established regardless of where the service was rendered.

Scenario #5: A 36-year-old male has been seeing the same FP for seven years but he moves to a new city. Five years later, he moves back and returns to his original FP. It would seem as though the patient would be considered established, Moore says, but technically he is new because more than three years have elapsed.