Primary Care Coding Alert

Question: Our clinic had a patient come in for a wellness visit. They had only been to our clinic once before and only to get a vaccine, and they didn’t see the doctor. Would this patient be new or established for the wellness visit encounter?

AAPC Forum Participant

Answer: This one likely will come down to a technicality, but it’s probably best to consider the patient to be established at the wellness visit. Here’s why.

First, let’s take a look at the CPT^® guidelines, which state, “An established patient is one who has received 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.” CPT^® goes on to define professional services as those “face-to-face services rendered by physicians and other qualified health care professionals [QHPs] who may report evaluation and management services reported by a specific CPT^® code(s).” Note also that the “service” does not have to be an evaluation and management (E/M), but it does have to be face-to-face.

Next, let’s consider vaccine administration. Vaccine administration is a face-to-face service that one reports with a specific CPT^® code, so it meets that part of the professional service definition. While it seems the vaccine was not administered by a physician or QHP, the service was probably billed under a physician or QHP’s provider number, listed in the “Rendering Provider ID #” space on the claim, which it would have needed to be even if a non-QHP performed the service (since they don’t have their own provider numbers). If so, then the service was technically rendered by a physician or QHP. If the rendering physician/QHP on the claim for the vaccine administration is of the exact same specialty and subspecialty as the wellness visit provider and is in the same group practice and the vaccine administration is within the past three years, then that puts the encounter squarely into established patient territory at the time of the wellness visit.