Primary Care Coding Alert

Question: Our office requires that new adult patients have a "new established visit." During the encounter, the family physician (FP) reviews the patient's medical history and addresses any pertinent issues. Most patients have multiple problems that require evaluation, which makes coding easy.

Some patients, however, need the FP to review only their history. How should we code these non-evaluation visits in which the physician establishes new patient care?

California Subscriber

Answer: This is a tough question because CPT doesn't describe a "new established visit." In fact, your terms contradict coding nomenclature. A patient is either new or established, not both.

You seem to be referring to a preadmission health review. Before your FP accepts a patient into your practice, he requires the individual to present to establish care.

This medically unnecessary reason, however, doesn't affect the visit's coding. You should instead report these encounters based on these guidelines:

1. If the FP performs a general physical examination, you should use a new patient preventive medicine services code (99381-99387, Initial comprehensive preventive medicine evaluation and management of an individual ...).

2. When the physician addresses a patient's problems, you may separately report the problem-oriented portion of the encounter with a new patient office visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). To submit this second E/M service, the FP must perform and document that the "sick" service is significant and separately identifiable from the well check.

3. If the FP only talks to the patient, chock the encounter up to office protocol. CPT provides no way to code a counseling and/or coordination of care encounter without a complaint.

Warning: A Medicare auditor may question the medical necessity of these establishing care visits. You may want to change your policy and either have patients schedule a full physical or delay their initial visits until they have a complaint.

- Answers to You be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, health information management certificate programs coordinator at Clarkson College in Omaha, Neb.; Jaime Darling, CPC, certified coder for Graybill Medical Group, which has nine family physicians, in Escondido, Calif.; Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.; and Jean Ryan-Niemackl, LPN, CPC, an application support specialist for QuadraMed in Fargo, N.D.