Urology Coding Alert

Tip: Start with the three-year rule.

When your urologist sees a patient in the office, the first question you need to ask yourself before choosing a code to report is whether you should be billing a new or established patient code. If you follow the three-year rule, the task seems easy — but when you factor in multiple locations, physicians from different specialties practicing in the same location, and non face-to-face services, the straightforward rule gets complicated.

Read on to learn how to navigate the sometimes complicated path and choose the proper new versus established patient code for every encounter.

3 Year Rule Determines Patient Status

“Generally, you should consider a patient to be established if any physician in your group (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months,” says Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co.

For example: A patient complaining of dysuria (pain on voiding) comes to your office. Although this is urologist A’s first time meeting the patient, urologist B, in the same group practice, saw the patient two years ago for a similar complaint. In this case, the patient remains as an established patient.

Don’t let different locations lead you astray: “If your practice has multiple locations, and a physician in location A sees the patient in January, but a physician in location B sees the patient the following December, the patient is still established. The need to create a new chart is inconsequential,” Hammer says.

Non-face-to-face encounters don’t count: A primary-care physician recommends that a 60-year-old female see the urologist regarding her urinary incontinence. During the previous year another urologist in the same practice interpreted some general blood test results for this same patient but did not provide a face-to-face service.

In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years.

According to section 30.6.7 of the Medicare Claims Processing Manual, “An interpretation of a diagnostic test, reading an x-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

Exceptions Could Occur for Different Specialties

The new patient rule applies when physicians in the same group practice are also of the same specialty.

In a nutshell: If your practice is a group practice which also includes other specialties, two physicians of different specialties may see a patient for completely different reasons. This would allow you to report a new patient visit even though these two physicians are in the same group practice and saw the same patient within a three-year period.

Example: An ob-gyn in a large multiple-specialty practice sees a patient in 2011 for infertility counseling. In early 2013, the same patient sees your urologist — who is a member of the same multi-specialty practice as the ob-gyn who earlier treated the patient — for an office E/M service regarding a possible bladder tumor.

Because the ob-gyn and the urologist (who are obviously of different specialties) saw the patient for completely unrelated problems, you may report the urologist’s initial visit as a new patient.

Consult Codes Don’t Differentiate

The older consult codes, 99241-99245, still in use by some non-Medicare payers, do not differentiate between new and established patients. Therefore, when billing for office consultations for  non-Medicare payers, regardless of the patient’s status, you should make your outpatient consult code choice from the 99241-99245 range.

When reporting consults and new patient E/M services, you’ll need to meet the requirements of all three key components (history, exam and MDM) to report a given level of service.

Short cut: “In effect, this means that whichever key component is the lowest will determine the E/M service level you choose,” Hammer says.

Example: During an office visit with a new patient, the urologist documents a comprehensive history, a comprehensive exam and MDM of low complexity. In this case, the physician has met the history and exam requirements for 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...) but the MDM requirement for only a 99203 visit. Because the level of the lowest key component/requirement also determines the E/M service level for new patient office visits, you must choose 99203 in this case.

The AMA added text to CPT^® in 2006 to clarify that all of the key components (history, exam and MDM) must meet or exceed the stated requirements to qualify for a particular level of service for office, new patient (99201-99205), hospital observation services (99218-99220), initial hospital care (99221-99223), office consultations (99241-99245), initial inpatient consultations (99251-99255) and others.

Alternative example: During an initial inpatient consultation, the urologist documents a detailed history, a detailed examination and MDM of moderate complexity. Because you have met or exceeded all three categories for a level-three service of this type, report 99253 (Inpatient consultation for a new or established patient ...).

2 of 3 Will Do for Most Established E/M Visits

When reporting most established patient outpatient E/M services (except consults and observation care, which do not distinguish new from established patients), you can assign an E/M level based on just two of the key components, Hammer says.

Example: The urologist sees an established patient with a new complaint. The physician documents a problem-focused history, expanded problem-focused exam, and low-complexity MDM. In this case, the history only meets the level of 99212, but because the other two components meet the requirements for 99213, you may report this higher-level service.

Per CPT^®, you must meet or exceed the stated requirements for two of the three key components for established patient office visits (99212-99215), subsequent hospital care (99231-99233), subsequent nursing facility care (99307-99310) and others.

Watch for Over-coding

Generally, medical necessity should determine the MDM level and, ultimately, the appropriate E/M service level. Physicians should not, for instance, report a comprehensive history and examination at every visit and expect to report 99215, regardless of the documented level of MDM.

Simply stated: If the presenting problem does not support a high-level E/M service, you should not be paid for a high level of care just because the physician documented a comprehensive history and examination.

Also remember that Medicare and many private and commercial payers follow the 2010 Medicare new rules for consultation coding. For these payers, office consultations are billed with 99201-99205 (Initial new patient ...) and/or 99211-99215. Inpatient consultations are billed with 99221-99223 (Initial hospital care ...) and/or 99231-99233 (Subsequent hospital care ...). In contrast to the above coding, for these consultation visits, you must distinguish between new and established patients beforehand and code accordingly to the status of the patient, new or old.

A final note: Remember, you may report E/M services based on time — rather than the key components of history, exam and MDM — if your urologist spends more than 50 percent of the visit on counseling and/or coordination of care.