Psychiatry Coding & Reimbursement Alert

Question: We have a new psychiatrist joining our practice. He has informed us that some of his established patients (from his previous place of practice) will be continuing to see him in our practice. So, when these patients visit him for the first time over here, should we bill the first visit with a new patient code, or should we consider these patients as established?

Illinois Subscriber

Answer: When determining whether to consider billing for these patients who have previously seen your psychiatrist as new or established, you should not use location in which the patients saw your clinician as a basis.

CPT^® clearly defines what qualifies as an established patient: “An established patient is one who has received 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.”

Based on CPT^®’s established patient definition, new versus established refers to the patient’s relationship to the physician, not his relationship to the practice or its location. So, even though the carryover patients that your clinician plans to see in your practice have never visited your practice, you still cannot report the services provided during the first visit to your practice using a new patient code if your clinician has seen them elsewhere within the past three years.

Remember:  To determine new or established patient payments, insurers will look at the provider’s National Provider Identifier (NPI), not where the services were provided each time the patient visited your clinician to avail these services.