Urology Coding Alert

For every patient your urologist sees for an office visit, your first coding task is to determine if the patient is new or established. Make your job easier by understanding the essential three-year rule.

Take a look at what the experts say about when -- and how -- you should apply the infamous three-year criterion.

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: CPT clearly defines what qualifies as an established patient: "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." Ask yourself, "Has the patient seen the urologist in the past three years?" Here's the best way to code based on your answer:

• Yes: If your urologist has billed for a professional service in the past three years for a patient, you'll report any subsequent visits using established patient E/M codes (such as 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), says Kathleen Goodwin, CPC, coding coordinator for La Porte Regional Physician Network in Indiana.

• No: If your urologist has not seen the patient within the past three years, you can report a new patient E/M code (such as 99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...), instructs Christy Shanley, CPC, billing manager for the University of California, Irvine department of urology.

If the patient has been seen before within the same practice, even though he switched doctors, he is an established patient.

"In a group physician setting, we are under the same tax ID," Goodwin explains. "So we have to determine if and when the patient has seen any of our doctors (of the same specialty) before we can decide on a new or established patient code."

Example: A urologist in your practice provides an initial inpatient consultation to a patient he's never seen before. The patient then comes to your office for followup care one week later, but sees a different urologist because the first urologist is unavailable. 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 ...). Even though the patient has never been to your office, and the second physician has never seen the patient, you should report an established patient code.

Remember: The patient is an established patient because a urologist in the same specialty and group provided professional services within the past three years.

Exception: The rules differ for subspecialties. If your practice has sub-specialists, you may have a situation when you should use new patient E/M codes for an otherwise established patient. Check with your individual payers to see how they define new and established patient visits with regard to different specialties and subspecialties in the same group.

You should not use the place of service (POS) as an indication of whether you are working with a new patient versus an established one. Based on CPT's established patient definition, new versus established refers only to the patient's relationship to the physician, not his relationship to the practice or its location.

"POS is irrelevant," Shanley says. Even if your urologist saw a patient in the emergency room rather than in your office, the next time your urologist or one of his associates sees that patient he is an established patient.

Guideline: If a physician 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).

All of these new versus established patient rules 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 established even if this is his first visit to your practice.

"If a patient's doctor leaves the practice but the patient starts seeing another doctor within that practice, it's an established patient," because the physicians (assuming they're in the same specialty) use the same tax ID, Goodwin says. "If that patient follows the doctor to a new location, he or she is still an established patient," she says.

To determine new or established patient payments, insurers will look at the urologist's National Provider Identifier (NPI), not where the service was provided.