Urology Coding Alert

Count the years since the patient's last visit to determine E/M coding

When your urologist provides an office or outpatient E/M service, your first challenge is determining whether the patient is new or established. By understanding CPT's three-year guideline, you'll be able to quickly make a determination and properly code for your physician's services.

CPT Provides Clear Definitions

The chief factor in determining whether a patient is new or established is time. You must decide whether your urologist 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 urologist has not provided professional services to the patient within the past 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 as 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 laboratory tests, do not count toward this rule. The services involved must include a face-to-face service and encounter.

Tip: These guidelines also apply to a new physician in your practice. If the new urologist has provided professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.

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 Codes and CMS guidelines do not vary on the definition of a new or established patient.

Therefore, if a urologist provides professional services to a patient in the hospital, all of his partners (physicians), with or without the same tax identification number, who provide 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 urologist in your group provides an initial inpatient consultation 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, Office or other outpatient visit for the evaluation and management of an established patient ...) because the urologist 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 urologist who saw the patient in the hospital is unavailable in the office and the patient is assigned to another urologist in the same practice for the follow-up visit. Even though the second physician has never seen the infant, you should report an established patient code because a urologist in the same specialty and group has provided professional services within the past three years.

No E/M Service Means New Patient

Medicare defines "professional services" as any E/M service that is a face-to-face visit. When a urologist provides services to a patient, and another urologist 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 (MCM) section 30.6.7.

Pay Attention to Multispecialty Guidelines

Remember that the rules differ for subspecialties. If your practice has subspecialists, you could potentially 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/specialists 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. 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 and be registered with a unique taxonomy code/number 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 (see www.wpc-edi.com/codes/taxonomy for a list of all specialties).

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."