Urology Coding Alert

Question: We have a new urologist in our group whose patients from his previous group followed him to our group. Some of the staff argues that we should code these patients' first visits in our practice as new patient visits. Some believe we should report them as established. What is the correct way of coding for these first visits to our practice for this new urologist?

California Subscriber

Answer: The chief factor in determining whether a patient is new or established is always time. You must de-cide whether your physician has seen the patient in the past, and if he has, how long ago. These guidelines also apply to a new urologist in an established practice such as in this case.

How it works: If the new urologist has provided face-to-face professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.

Rule: To determine a patient's status, use CPT's established patient definition: "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."

If your physician has seen the patient for a professional service in the past three years, you'll report any subsequent visits with established patient E/M codes (such as 99211-99215).

Remember: Professional services that do not involve a face-to-face encounter, such as interpreting an x-ray or reviewing laboratory tests without seeing the patient, do not count toward this rule. The services involved must include a face-to-face service and encounter.

-- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis.