Primary Care Coding Alert

Question: Our group uses the same tax identification number for a family practice clinic and a pediatrics department. When a patient turns 18, family physicians, rather than pediatricians, provide treatment. Should I consider the patient new or established?


Texas Subscriber


Answer: The patient meets CPT's definition of a new patient. You may code the first face-to-face encounter involving a family physician and prior pediatric patient with 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 (for instance, 99212-99215, (Office or other outpatient visit for the evaluation and management of an established patient -)

When physicians operate under the same group number, specialty impacts a patient's status. -A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years,- states CPT's notes for new and established patients. Therefore, a patient may qualify as a new patient even if he has received professional services from several physicians in the group and a medical record is available.

Best bet: Look at the provider's specialty to determine whether you should consider a patient new. If the physicians use different CMS specialty codes, such as 08 for family practice and 37 for pediatric medicine, you can report 99201-99205 on the first encounter involving a doctor with an unused designation.

Example: At Primary Care Associates XYZ, an 18-year-old female patient who has been under the care of the group's pediatricians requests the team's FPs treat her in the future. The individual presents for an annual preventive medicine service to one of the group's FPs.

At this encounter, the patient qualifies as a new patient even though the FP may refer to her established medical record. So, you should report 99385 (Initial comprehensive preventive medicine evaluation and management of an individual - 18-39 years) instead of 99395 (Periodic comprehensive preventive medicine reevaluation and management - 18-39 years).

You should also code a patient as new if the first face-to-face encounter involves a patient who transfers from a multi-specialty group's obstetricians (specialty code 16) to its FPs. For a listing of qualifying specialties, download file www.cms.hhs.gov/providers/enrollment/taxonomy.pdf.

Public-relations consideration: Although you can technically count the patient as -new- from a CPT perspective in these scenarios, good patient relations may dictate that you bill the encounters as established. Patients may question why you-re charging them as new when they-ve been patients in the practice for years. This is especially true if the patient's coinsurance is a percentage of the allowed amount. Insurers usually pay new patient codes at a higher allowance than established patient [...]