Primary Care Coding Alert

Mythbusters:

Bust These Myths, Distinguish New vs. Established Patients Correctly

Published on Wed Feb 16, 2022

There’s more to determining patient status than the 3-year rule.

With all the changes to the office/outpatient evaluation and management (E/M) services in the last few years, it’s easy to forget that some guidelines for 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/ established patient …) have remained the same. CPT^®guidelines for determining whether a patient is new or established to your practice are a good example of guidelines that haven’t changed.

This means there are still some lingering myths about the guidelines that need to be dispelled. Here are three of the most common, along with two very good reasons why you need to determine patient status correctly.

Why Is the New/Established Patient Distinction Important?

First, “misidentifying a new patient as established poses a billing risk, as the reimbursement is higher for a new patient at the same level of service,” due to the extra work typically involved in taking the patient’s history and diagnosing new conditions, explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. For example, the 2022 Medicare national nonfacility fee for an established patient level-3 office/outpatient E/M (99213) is $92.05, whereas the fee for the corresponding new patient E/M, 99203, is $113.85, a difference of $21.80.

But the second reason your office needs to make the distinction correctly may be more important. “You could also be facing compliance issues,” Falbo warns.

Myth 1: Patients Who Receive Immunization Services From a Practice Automatically Become Established

Consider a patient who has not previously seen any of the physicians or qualified healthcare professionals (QHPs) in the practice and who comes in solely for a flu immunization. A nurse administers the shot, and you report 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)), along with the appropriate code for the flu vaccine product, but you report no office/ outpatient E/M service on that date of service. Several weeks later, the patient returns. Your provider performs an office/ outpatient E/M service at that time, and you report the service with an established patient code.

This coding would be incorrect. CPT^®defines an established patient as “one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years” (emphasis added). CPT^®also states, “Solely for the purposes of distinguishing between new and established patients, 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)” (emphasis added).

In the scenario above, the returning patient has only received a flu shot from a nurse and received no professional services from the physician or other QHP in the practice. As such, the patient does not meet the CPT^®definition of “established.” “If the patient sees a provider at some point during the next three years following the flu shot, the patient is still considered new the first time they receive a professional service from the provider in this situation,” explains Donelle Holle, RN, president of Peds Coding Inc. and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

So, in this case, you should use a new patient office/outpatient E/M for the first encounter with a provider after the flu shot and use an established office/outpatient E/M for the E/M services provided during the patient’s subsequent encounters.

Myth 2: Patients Who See Two Providers With Different Specialties in the Same Practice Are Automatically Established After the First E/M

This myth is particularly tricky to dispel, as often different providers practicing in different specialties may be billing under the same group taxpayer identification number (TIN), making it seem like the billing is the same regardless of provider specialty.

However, TINs are not the determining factor to determine specialty and subspecialty differences. Providers also have different taxonomy codes that indicate different specialties.

As an example, take an adolescent patient who has been seen by a pediatrician and who then transitions into adult care and is seen by a family physician in the same practice for the first time. The pediatrician and family physician both bill under the same practice TIN, but they have different taxonomy codes and are therefore regarded as practicing in a different specialty.

In this case, the patient’s first appointment with the family physician would be as a new patient, assuming the patient had not seen that provider or another family physician in the group practice within the three years prior to that first appointment.

Myth 3: E/M Services Provided by a Nurse Are Automatically Reported as 99211

Because 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) does not require the presence of a physician and requires no history, exam, or medical decision making (MDM), you may assume you can use the code for a new patient who receives office/outpatient E/M services from a nurse practitioner, (NP), a physician assistant (PA) or any other nonphysician practitioner (NPP). However, this is a myth for three very good reasons.

First, “CPT^®describes the 99211 service as being for an established patient, so it cannot be used for a new patient,” Holle explains.

Second, the code can only be for established patients because if the service is provided by someone other than a physician or other QHP, the service will still be reported under the supervising physician or QHP’s provider number. Medicare regards this service as incident to the physician, and you cannot provide incident-to services to a new patient because one of the many requirements for incident-to reporting is that there must be a course of treatment in place, which isn’t true for a new patient.

Lastly, QHPs, including NPPs, are eligible to report any appropriate level of E/M service. Thus, if a QHP sees a new patient, that encounter may be reported with 99202 at a minimum, which is not only more appropriate coding but also pays better than established-patient code 99211. As Holle notes, “if a new patient comes in, it is best practice to have the patient seen by the provider who will initiate a care plan and may report the appropriate level of new patient office/outpatient E/M service.”