Pulmonology Coding Alert

Tip: Count the years since the patient's last visit before choosing an E/M code

When your pulmonologist provides an office or outpatient E/M service, you can't begin to code his work until you determine if the patient is new or established. If you understand CPT's guidelines, you'll be able to quickly differentiate the two and guarantee proper coding for your physician's work.

CPT Provides Clear Definitions

The chief factor in determining new or established is time. You need to look at whether your pulmonologist has seen the patient in the past, and if he has, how long ago.

Rule: To determine a patient's status, use CPT's established patient definition: "An established patient is one who 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."

If the pulmonologist has not provided professional services to the patient within the last three years, you should use new patient E/M codes (such as 99201-99205). If your physician has billed the patient for a professional service in the past three years, you'll report any subsequent visits with established patient E/M codes (such as 99211-99215), says Beth Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants in Winston-Salem, N.C.

Professional services that do not involve a face-to-face encounter, such as an x-ray or a pulmonary function test interpretation, do not count toward this rule. The services involved must include a face-to-face service.

Tip: These guidelines apply even to a new physician in your practice. If your new pulmonologist has provided professional services to a patient elsewhere, such as a hospital, within the last 36 months, the patient is an established patient whether this is his first visit to your practice or not.

Don't Focus on Location

Look at your physician's specialty, time, and tax ID number, not location or insurer, when deciding a patient's status. CPT and CMS guidelines do not vary on the definition of a new or established patient.

Therefore, if a pulmonologist provides professional services to a patient in the hospital, any physician who has the same tax identification number and provides subsequent office or outpatient care must consider the patient an established patient and bill the appropriate established patient office visit code (99211-99215).

The place of service is irrelevant to the new/established patient definition; new or established refers to the patient's relation to the physician(s), not the patient's relation to the office, Janeway says.

Example: A pulmonologist in your group provides an inpatient consult to a 1-year-old child he's never seen before. The patient then comes to your office for follow-up care one week later.

You should report an established patient office visit for the physician's in-office follow-up (99212-99215) because the pulmonologist performed the follow-up care within three years of the hospital encounter (such as 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). The patient is an established patient even though he has never been to your office.

The same coding applies if the pulmonologist who saw the patient in the hospital is unavailable and the patient is assigned to another pulmonologist in the same practice. Even though the second physician has never seen the infant, a pulmonologist who is in the same specialty and group has provided professional services within the past three years, which meets CPT's definition of an established patient.

No E/M Service Means New Patient

Medicare defines "professional services" as any E/M or face-to-face service. When a pulmonologist provides services to a patient, and another pulmonologist in the same group furnishes services before three years have elapsed, you should consider the patient established.

"If no evaluation and management service is performed, the patient may continue to be treated as a new patient," according to the Medicare Carriers Manual section 30.6.7.

Pay Attention to Multi-Specialty Guidelines

Remember that the rules differ for subspecialties. If your practice is established as a multi-specialty group that reports under the same tax ID number, you could have a situation in which you use new patient E/M codes for an otherwise established patient.

If a subspecialist has a specialist distinction that is different from that of the physician/specialist who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient per the June 1999 CPT Assistant, says Stacie L. Buck, RHIA, LHRM, president and founder of Health Information Management Associates Inc. in North Palm Beach, Fla. You should also learn how your individual carriers define new and established patient visits with regard to different specialties and subspecialties in the same group, she adds.

The difference: The subspecialist must have a unique tax code for his subspecialty, and the patient must not have seen any other physician who provides services of the subspecialty for the practice within the last three years.

Best bet: Obtain written confirmation from the payer as to its specific requirements. Each carrier and payer may vary on what counts as "different specialties."

Public-relations consideration: Although you can technically count the patient as "new" in these scenarios, good patient relations may dictate that you bill the encounters as established. Patients may question why you're charging them as new when they've been patients in the practice. This is especially true if a patient's coinsurance is a percentage of the allowed amount.
 
Insurers usually pay new patient codes more than established patient codes. If you choose to report new patient services for this situation, inform and educate the patient.