Pulmonology Coding Alert

Question: We have a cardiothoracic surgeon and a cardiologist on staff at our multispecialty clinic. If a patient sees each of them but is new to our pulmonologist, can we report new patient codes (99202-99205) or should we report established patient office visit codes (99211-99215)?

California Subscriber

Answer: If your practice is a multispecialty practice and the patient has been seen by a physician from a different specialty within the practice before seeing your pulmonologist, you should not necessarily consider that patient as an established patient. If the patient has seen a physician from another specialty in the past three years but has not received services from your pulmonologist or any other pulmonologist in the group in the past three years, then the patient should be considered “new” and not “established” when they see the pulmonologist.

The definition of established patient includes the phrase “exact same specialty and subspecialty who belongs to the same group practice.” That means that if the patient is seeing physicians from different specialties within the group in a three-year span, then the patient may be a “new” patient for one physician in a given specialty even though he has seen a physician from another specialty in the group.