Primary Care Coding Alert

Question: I work for a hospital that owns multiple family practice clinics. If a patient goes to one family practice clinic and then decides to switch to another clinic, which is still owned by the hospital, would the patient be considered a new patient or an established patient for the purposes of office/outpatient evaluation and management (E/M) service coding?

New York Subscriber

Answer: CPT^® defines a new patient as “one who has not received any 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.”

The key part of this definition that applies in your case is the phrase “same group practice,” which refers to any group of physicians billing under the same tax number. So, if the hospital-owned practices all bill under that ID, and your patient has been to one of them in the previous three years before switching to another practice under the same ID, then the patient would be regarded as an established patient, and you would bill any office E/M services using 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …).