Primary Care Coding Alert

Question: A case manager meets with our obstetric patients before they see the family physician. The manager assesses the patient's risk, starts her paperwork and discusses payments. We include these services in our OB package and don't separately bill for them. The patient then returns a few days later for the initial prenatal workup, including Pap smear, physical, etc. Should I report a new or established patient visit for the patient-physician encounter?

Arizona Subscriber

Answer: The patient is new to the physician as long as your FP -- or, if you're in a group practice, another FP in your same group - hasn't provided any professional services to the patient in the past three years. CPT's new or established patient definition doesn't relate to when staff start the patient's medical record. The definition instead deals with the physician-patient relationship.

The professional service refers to a face-to-face service that a physician renders and reports with a CPT code. If your FP or another FP in your same group practice hasn't billed the patient for a face-to-face service represented by a CPT code in the past three years, you should bill the encounter as a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...).

-- Information for You Be the Coder and Reader Questions provided by Emily Hill, PAC, president of Hill & Associates, a consulting firm in Wilmington, N.C., Rudy Tacoronti, MD, director of occupational medicine for DeKalb Health Systems in Decatur, Ga; and George Ward, billing supervisor with South of Market Health Center in San Francisco.