Urology Coding Alert

Question: I’ve heard mixed opinions on the difference between a new and established patient from an E/M coding perspective. I’ve heard that you can consider a patient new even if they’ve been to your practice before. Is that true?

Nevada Subscriber

Answer: Quite obviously, if your practice sees a patient for the first time ever, you should choose a new patient E/M code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …). There are also times when you should consider a patient “new” even if she’s been a patient at your practice before.

The chief factor in determining whether a patient is new or established is time. You must decide whether you have seen the patient in the past, and if you have, how long ago. According to WPS Medicare, a new patient “has not received any professional services from the physician within the previous three years. Physicians inthe same group practice who are in the same specialty must bill and be paid as though they were a single physician.”

For coding purposes, an established patient “has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years,” states WPS Medicare.

Potential exceptions: If your practice includes sub-specialists, and the payer allows it, situations might arise in which new patient E/M codes are appropriate for an otherwise established patient.

Best bet: Look before you leap. Contact your payers and ask how they apply new and established patient guidelines — specifically in regards to different specialties and sub-specialties in the same group practice.