Pulmonology Coding Alert

Question: A provider insurance representative recommended at an in-house seminar that when our pulmonologists see new patients in the hospital, we can still bill them as new patients in the office as well. But when one of our pulmonologists treats a patient in the hospital whom he later sees in our private practice, I've been considering those patients to be  established patients. Who is correct?

New York Subscriber

Answer: You are correct. 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."

Strategy: Show the insurance representative CPT's new and established patient definition under the heading "Definitions of Commonly Used Terms" in Evaluation and Management Services Guidelines. The representative may be unfamiliar with in-office coding that follows this rule.

A patient's status doesn't affect hospital care coding. For instance, you report initial hospital care with 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) and subsequent hospital care as 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...), regardless of whether the patient is new or established.

But if one of your pulmonologists treats a patient in the hospital and later (within three years) treats the patient in the office, you must code the encounter as an established patient E/M service, such as 99212-99215 (Office visit for the evaluation and management of an established patient ...).

- Answers for You be the Coder and Reader Questions were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia; and Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy and Critical Care at Emory University School of Medicine in Atlanta.