Primary Care Coding Alert

Question: A physician in our group provides an E/M service to a hospital inpatient. If the patient then comes to our office for follow-up care, should I charge a new or established patient visit? Should I code the scenario differently based on CPT versus Medicare guidelines?

Texas Subscriber

Answer: You should report an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient -) if an FP performs the follow-up care within three years from the hospital encounter (such as 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient -). Specialty and time, not location or insurer, affect a patient's status. CPT and CMS guidelines do not vary on the definition of a new or established patient.

To determine a patient's status, you should use CPT's established patient definition: "An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." Medicare defines "professional services" as an E/M or other face-to-face service.

Therefore, when an FP provides services to a patient, and another FP in the same group furnishes services before three years have elapsed, you should consider the patient established.

If your group includes multi-specialties, an office visit following a hospital encounter could qualify as a new patient service. For instance, a gastroenterologist may have seen the patient in the hospital and recommended that the patient follow up with your office. The patient sees an FP within the same group for follow-up care.

In this case, you could code a new patient code (such as 99201-99205, Office or other outpatient visit for the evaluation and management of a new patient -), instead of an established patient code.

Each carrier and payer may vary on what counts as "different specialties."

Best bet: Obtain written confirmation from the payer as to its specific requirements.