Primary Care Coding Alert

See how changes affect your use of 99201-99205, 99460-99461, and more.

Coding guidelines can sometimes seem confusing when you're trying to decide whether to classify a patient as new or established. For example, when an established patient presents to your practice to see a new physician, should you report a new patient office visit code?

CPT® 2012 attempts to clarify this question and one other E/M stumper: Who counts as a "qualified healthcare professional" to administer that vaccine or provide prolonged service?

'New Patient' Classification Goes to a New Level

Currently, CPT® indicates that a "new patient" refers to a patient who has not received any professional services, such as an E/M or other face-to-face service, from the physician or another physician of the same specialty in the same group practice within the past three years.

Clarification: CPT® 2012 takes that definition a step further, by stating, "A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years." The portions of the description that are new for 2012 are underlined.

What it means: If your practice employs various subspecialists, CPT® now makes it clear that claims for patients who see different doctors with different subspecialties can be billed using a new patient code (such as 99201-99205), according to Peter A. Hollmann, MD, chair of the CPT® Editorial Panel.

"We'll have to wait and see if this will make a difference in how our local Medicare carriers handle new patient claims," says Linda Vargas, CPC, CEMC, coding and reimbursement specialist with Cass Regional Medical Center in Harrisonville, Mo. "Medicare has generally followed the same CPT® rules, but further defined it by saying that providers with the same tax ID and same specialty are the same provider in their eyes, regardless of location."

RN Doesn't Fit 'Other Qualified Healthcare Professional'

If your payer follows CPT® rules, you can now exclude registered nurses from the list of professionals who can administer vaccinations or provide prolonged services for patients.

At the request of many physicians, CPT® 2012 now defines the term "other qualified healthcare professional." Although this definition didn't make it into the 2012 manual, the AMA lists it as part of the "CPT® 2012 Errata" on its Web site (www.ama-assn.org/resources/doc/cpt/cpt-2011-corrections.pdf). The definition is as follows:

"A 'physician or other qualified health care professional' is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service. These professionals are distinct from 'clinical staff.' A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service. Other policies may also affect who may report specified services."

Result: "RNs and LPNs aren't included in the definition, because they cannot independently report the professional services that they provide," explains Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. RNs and LPNs fit the CPT® definition of "clinical staff," since their professional services are typically reported under a physician or other qualified health care professional's identification number (e.g., under Medicare's "incident to" rule). "This means that when certain CPT® codes refer to 'other qualified health care professionals' they are excluding RNs and LPNs," Moore says.

Example: Immunization administration codes 90460-90461 refer to "counseling by physician or other qualified health care professional." Thus, counseling by an RN or LPN would not qualify to meet the requirements of these codes. Other examples include cognitive testing code 96125 and prolonged service E/M codes 99358-99359.

Bright side: If your payer does not follow CPT® rules on this issue, you may still be able to allow an RN or LPN to perform the service that CPT® restricts to "other qualified health professionals," depending on what your insurer states in writing. And remember that state and local laws specifically dictate who can perform each type of service based on scope of practice, so look to your state medical society for information on that as well.