Primary Care Coding Alert

Use this ammunition to challenge 99201-99205 multispecialty denials

Government payers may thwart your attempt to bill multispecialty-care transfers as new patients. Find out when it's OK to do so.

Case study: A young patient who has been under the care of a pediatrician now wants to go to his parents- doctor and chooses to see a family physician in the same group practice. Should you code the FP-patient encounter as a new patient office visit? The answer depends on the guidelines you follow.

Group Patient + New Specialty = New Patient

You know you should consider a patient established when a family physician in your group has already provided professional services to the patient within the past three years. And when the patient has already seen another specialist within your group, you may still consider him new, says Emily Hill, PA, president of Hill & Associates in Wilmington, N.C. -For both CPT and Medicare, the definition of a new patient references different specialties,- Hill tells The Coding Institute.

Official word: See what you can extrapolate from the two main guideline creators.

1. CPT defines a new patient as -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- (emphasis added).

2. In the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 -Physicians in Group Practice,- CMS issues these instructions: -Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician - Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.-

Lesson learned: -In a multispecialty practice, a patient might be considered new even if he or she has received care from several other physicians in the group and a medical record is available,- writes Hill in -Understanding When to Use the New Patient E/M Codes- in the September 2003 Family Practice Management published by the AAFP. The patient's status depends on the physician's specialty designation.

Hill recommends coding the case study with 99201-99205. -When she sees the family physician, she-ll qualify as a new patient because the family physician is in a different specialty than her previous physician,- she says. Although the FP may treat her for an existing problem and refer to her established medical record, 99201-99205 are still a valid selection, she says.

Carriers May Impose Their Own Interpretation

Unfortunately, your coding peers are having problems with these recommendations. -Because we are a multi-specialty clinic, including ob-gyn, FP, internal medicine, orthopedics, general surgery and pediatrics, we are constantly involved with visits like the case study describes,- says Lisa Linville, CPC, in Missouri. Although Medicare and Missouri Medicaid previously accepted 99201-99205 in these instances, the government payers have now changed their stance.

Problem: If you code these encounters as new patient visits, the carriers will deny the claims. -Other insurers are following Medicare's lead,- Linville adds. -Their interpretation is if a group shares the same tax ID number they also share the same records.-
 
Don't Give Up on 99201-99205

If a carrier, such as Missouri Medicare, interprets the guidelines differently, challenge its policy. -Raise the issue with your CMS regional office,-says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.  Ammunition: Reference the explicit language in the Medicare Claims Processing Manual, noted above.

Also, make sure to remember the three-year limit for new patients, adds Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City. -Many patients are gone for three years or more, and when they come back we need to make sure to code them as new (99201-99205),- Fick says.