Pulmonology Coding Alert

Question: We know a new patient is one that our pulmonologist hasn’t seen in the past three years, but we have an unusual situation. Our pulmonologist has offered his opinion on chest X-rays for a particular patient but we never actually saw the patient until this week. Is the patient new or established in this case?

Massachusetts Subscriber

Answer: This patient is new, despite the chest X-ray reading.

As most practices are aware, 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.”

If, however, the doctor simply interpreted a diagnostic test (for example, a radiological or lab test) for the patient but never saw them face-to-face, in that case you should qualify for a new patient visit.

Know where other providers stand: This rule doesn’t just apply to MDs and DOs. Visits with other providers in pulmonology group such as physician assistants and nurse practitioners count toward the three-year rule.