Pulmonology Coding Alert

Question: Our pulmonologist recently saw a pediatric patient who was seen six months before by another member of our pulmonology group, who has since left. The child’s parents requested a second opinion on the prognosis for their child, who had cystic fibrosis. Our physician performed an extensive multisystem exam, reviewed the lengthy medical record, and spent 75 minutes counseling the parents. Will this patient be treated as a new patient? How should we code this encounter?

Arkansas Subscriber

Answer: No. According to the American Medical Association (AMA), the difference between a new patient and an established one is the following:

• A patient is new if he has not received any professional services (i.e., those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT® code[s]) from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

• A patient is established if he has received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Therefore, in your case the patient is established because the patient was seen in the practice within the preceding three years and you may report a standard E/M code out of 99211-99215 (Established Patient Office or Other Outpatient Services). Based on your description of a 75 minute established patient office visit, if you spent and documented more than 30 minutes on counseling/coordination of care, you would select 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:…). You can also report prolonged services if you have reached the threshold for the highest-level code and still had uncaptured minutes totaling 30 minutes or more.

Therefore, you can use +99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) with 99215 provided you are selecting the base code based on HEM, not time. When selecting the code based on time, you bill the highest level (e.g., 99215) and then use a prolonged service code to capture any additional time that is 30 minutes or more over the typical minutes involved with the highest level.