Primary Care Coding Alert

Question: A family practice provider in our large practice saw a patient, and the patient was billed for a new patient office/outpatient evaluation and management (E/M) visit. Several weeks later, the patient was referred to an internal medicine provider within the same practice who has a different taxonomy code from the family physician. Is this patient now considered established, or do we charge a new patient E/M for the internist?

AAPC Forum Participant

Answer: Per CPT^®, a new patient is defined as “one who has not received any professional services from the physician/ qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years” (emphasis added).

In your case, even though the two providers are practicing in the same practice, they are practicing under different taxonomy codes, meaning they are practicing in different specialties. This would be true even if both providers are billing under the same group taxpayer identification number (TIN).

This means the patient is regarded as a new patient to the internist. So, you can go ahead and bill a new patient E/M for the patient’s visit to the internist, assuming neither the internist nor another physician or qualified healthcare professional of the same specialty and subspecialty has seen the patient within the three years prior to the current E/M visit.