Urology Coding Alert

Question: I heard there will be changes in 2012 to when we should report a new patient code and when we should report an established patient code? When an established patient comes in to see a different physician that he's never seen before, should I report a new patient office visit code?

New York Subscriber

Answer: Currently, CPT® indicates that a "new patient" refers to a patient who has not received any professional services, such as an E/M or other face-to-face service, from the physician or physician group practice -- within the same physician specialty -- within the past three years.

Clarification: CPT® 2012 takes that definition a step further, now stating, "A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years." The portions of the description that are new for 2012 are underlined.

What this means to you: If your practice employs various subspecialists, CPT® now makes it clear that you can bill claims for patients who see different doctors with different subspecialties using a new patient code [such as 99201-99205], according to Peter A. Hollmann, MD, chair of the CPT® Editorial Panel, during the CPT® 2012 Annual Symposium in Chicago on Nov. 16:

Example: Your practice employs a general urologist and a urogynecologist, and both physicians are classified as these separate specialties with your payers. The urologist refers a patient to the urogynecologist for consideration of a paravaginal defect repair procedure and mesh placement. In this situation, the visit with the urogynecologist should qualify as a new patient visit, assuming the payer accepts these CPT® rules.