Primary Care Coding Alert

Hint: Patient status determined by physician relationship, not by POS.

Whenever a patient sees your FP for an E/M encounter in the office, a first step to determining the appropriate E/M code to report for the visit is knowing if the patient is “new” or “established.”

Bust these 4 common myths that will help you overcome coding hurdles and help you better understand the rules for when to report a new patient E/M code and when to use an established patient E/M code.

Myth 1: Patient Once Seen is Always Established

Reality: This is not true. According to CPT^®’s definition of 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.

So, if the patient has not visited your clinician or any other physician in your specialty or subspecialty in the same group in the past three years, then you can report the E/M encounter that the patient has with an appropriate new patient E/M code.

Reimbursement: Apart from raising red flags for coding wrong between new patient E/M codes and established patient E/M codes, you also stand to lose out on deserved pay if you are reporting an established patient code when you should have reported a new patient E/M code. For instance, you would be foregoing about $63 in reimbursement under Medicare if you report 99215 instead of 99205. The 2016 non-facility total relative value units (RVUs) for 99205 are 5.82 RVUs while 99215 carries 4.07 total RVUs in the non-facility setting. This translates to a Medicare reimbursement of $208.38 for 99205 while you will only receive $145.72 for 99215.

So, you will lose out on deserved pay if you mistakenly report an established patient E/M code when you actually could have reported a new patient code. Hence, whenever your clinician performs an E/M service for a patient that he or any one in the same specialty within the group has seen before, don’t be in a hurry and report an established patient code. Check when your clinician or the other physician has last seen the patient and if the time gap has been more than 3 years, report the encounter with a new patient E/M code.

Caution:  “Most patients will not be familiar with the CPT^® definitions of ‘new’ and ‘established’ patients, so if they have come to the practice before, they may think of themselves as ‘established,’ regardless of how long it has been,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “If you are going to adhere to the CPT^® definitions in this situation, it may be helpful to let the patient know in advance of billing that, because you have not seen them in the past three years, they will be considered ‘new’ at this encounter. That may help avoid unpleasant surprises when the patient gets the bill, especially since new patient visits are priced higher than the corresponding level of established patient visits,” Moore adds.

Myth 2: Patient Seen by any Physician is Established

Reality: If your practice is a multispecialty practice and the patient has been seen by a physician from a different specialty within the practice before seeing your FP, you should not necessarily consider that patient as an established patient. If the patient has seen a physician from another specialty in the past three years but has not received services from your FP or any other FP in the group in the past three years, then the patient should be considered “new” and not “established” when they see the FP.

The definition of established patient includes the phrase “exact same specialty and subspecialty who belongs to the same group practice.” That means that if the patient is seeing physicians from different specialties within the group in a three year span, then the patient may be a “new” patient for one physician in a given specialty even though he has seen a physician from another specialty in the group.

Example: A cardiologist in your multispecialty practice saw a 46-year-old female patient with complaints of chest pain on 7/7/14. The patient was a new patient to the physician and the practice at that time. She was evaluated by your cardiologist, and the encounter was reported with a new patient code 99204. The same patient was not served again by your practice until she reported to your practice with complaints of earache and tinnitus on 6/6/16. The patient was evaluated by your FP. Even though the patient was seen in your practice within a span of 3 years, you will still report this encounter with a new patient E/M code as the patient saw a physician from another specialty during the initial encounter.

“This is another area in which a patient’s lack of knowledge of the CPT^® definitions may necessitate deviating from what is technically permissible to code for the sake of patient relations,” Moore says. “Explaining to a patient that they are ‘new’ because they saw an FP today and a cardiologist in the same practice two years ago will be difficult, bordering on impossible. To avoid patient disgruntlement and potential bad word of mouth about the practice, it may be preferable to code the encounter with the FP as ‘established,’ even though that is technically incorrect and results in lost income to the practice for that encounter.”

Myth 3: All Previous Services Provided to Patient Make the Patient “Established”

Reality: According to the definition for an established patient, if a patient has received professional services from the physician within a span of 3 years, then the patient is considered to be an established patient. 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).”

So, in order to determine whether the patient is new or established, it is essential to know if any previous services the patient had with your physician or any other physician from your same specialty or subspecialty in the group were “face-to-face.” Only face-to-face services that can be reported with a specific CPT^® code(s) count as “professional services” for purposes of determining whether an encounter that the patient had with your physician face-to-face can be reported with a new or established patient E/M code.

For instance, imagine your FP only performed the interpretation and report of an electrocardiogram (ECG) and did not actually meet the patient on 2/10/16. During the next visit on 3/10/16, your FP met the patient and performed an E/M service. This succeeding visit on 3/10 may be reported with a “new” patient E/M code, assuming all of the other elements of the new patient definition are met, because the ECG interpretation was not face-to-face and, therefore, not a professional service in this context.

Myth 4: FP Seeing Old Patient in New Practice Calls For New Patient Code

Reality: If your FP has recently joined your practice and he has some carryover patients from his old practice, you cannot automatically report the encounter your clinician has with these patients in your practice with a new patient code. CPT^®’s definition makes it clear that new versus established refers to the patient’s relationship to the physician, not his relationship to the practice or its location.

So, irrespective of where the patient has met your FP in a previous encounter, you will continue to report all subsequent encounters the patient has with your FP in a 3 year span with “established” patient codes. Hence, all carryover patients from the old practice will continue to be “established” patients, assuming the FP has provided face-to-face services to them within the past three years, even though they are turning up in your practice for the first time ever.

Reminder: Likewise, if any of your clinicians is seeing a patient in another location such as in an emergency ward of the hospital prior to seeing the patient for the first time in your practice, you will report the encounter in your practice with established patient codes as your clinician has seen the patient before.