Urology Coding Alert

Question: We have several new urologists starting with our practice. Some of their patients are following them from their previous practice. We have been billing these as new patients since they are new to our practice. We are not receiving denials. However, the office staff from the other practice is telling us we should be billing these as established patients since the urologists have seen the patients in the last year. Who is correct?

Kentucky Subscriber

Answer:  The coders at the other practice are correct, if the urologists have seen the patient within the last year.

Here’s why: The key factor in determining new versus established is time. If the urologist has seen the patient within the past three years, the patient is established with that provider. 

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.” 

Based on this 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. If your new urologists have provided professional services to a patient elsewhere, such as in a hospital or another practice within the last 36 months, the patient is established even if your are coding his first visit to your practice.

Best practice: Ask yourself, “Has the patient seen this urologist in the past three years?” Code based on your answer, as follows:

• Yes: If your urologist has billed for a professional service in the past three years for a patient, 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 ...).

• 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 ...).

Tip: Have the urologist document whether or not he has seen the patient at his previous practice in the past three years. “We have several providers this pertains to in our practice at the moment, and it can be difficult to keep track of which patients are new and which are established already,” says Leah Gross, CPC, CUC, coding lead at Metro Urology in St. Paul, Minn.  “We’ve encouraged them to document within the office note that the patient was a previous patient of theirs. Also, we’ve encouraged them to state the last time they saw the patient, because some of these patients haven’t been seen within three years by our provider, and truly are now considered new.”