Cardiology Coding Alert

Even if the patient has been to your office before, she might be new

Proper coding for various E/M services rests on determining whether a patient is new or established, as defined by AMA guidelines. Now, a foolproof decision is only a few questions away.

'3-Year Rule' Still Applies

If your practice has never seen a patient before, that patient is automatically "new." In addition, if the same cardiologist hasn't seen the patient within the past 36 months, you may likewise consider the patient "new" from a coding standpoint, says Kelly Cookmeyer, CPC, cardiology coder for Acadiana Computer Systems (ACS) in Metairie, La.

Example: Your cardiologist meets with a patient in the office at the patient's request (in other words, the service is not a consult). Although the cardiologist has seen the patient in the past, the last visit occurred more than three years before. In this case, the patient is new rather than established. Therefore, you would choose a code from the new patient outpatient services category (99201-99205) rather than the established patient outpatient services category (99212-99215).

If the same cardiologist sees the patient at any time within a three-year timeframe, you must consider the patient to be "established," even if the patient was seen at different locations, Cookmeyer says.

In other words: Location isn't an issue when determining new versus established.

Example: A group practice maintains two offices on separate sides of town. A patient sees general cardiologist "A" for a complaint of chest pain at location "Y." Six months later, the same patient sees general cardiologist "B" in the same group practice for a new complaint at location "Z."

In this case, the patient is established -- even though the encounters took place at separate locations and involved separate cardiologists.

Here's why: Because the cardiologists are of the same specialty and billing under the same group number, the three-year rule applies. Had the cardiologists been of different specialties -- or if they belonged to different practices -- the second cardiologist may have been able to report the patient as "new" as long as she hadn't seen that patient within the previous 36 months.

Face-to-Face Matters

As in past years, the new-vs.-established-patient guidelines apply only to face-to-face services. Therefore, if a physician (or another physician billing under the same group number) provided a non-face-to-face service for a patient and then provided a face-to-face service within three years, you should still consider the patient to be "new" when selecting an E/M service code for the face-to-face encounter.

Example: The cardiologist meets with a patient for the first time for a new complaint. Another of the cardiologists in the same practice interpreted some test results for the same patient the previous year but provided no face-to-face service.

In this case, the cardiologist providing the current service may still consider the patient to be new when selecting an initial E/M code, Cookmeyer says. Here's why: No physician within the group practice provided the patient with a face-to-face service within the past three years.

Different Specialties Can Make the Difference

When physicians of different specialties see the same patient within the same 36-month period, the usual new- vs.-established-patient rules do not apply.

Specifically, if a physician of a different specialty -- or different practice -- sees a patient for the first time, you may consider the patient to be new even if she has seen other physicians within the group practice during the previous three years.

Example: A radiologist in a multiple-specialty practice sees a patient in 2005 for a mammography. In early 2007, the same patient sees a cardiologist (a member of the same multispecialty practice) for an office E/M service regarding a sudden onset of congestive heart failure.

Because the cardiologist and radiologist are obviously of different specialties, you may report the cardiologist's initial visit with the patient using the new patient codes, says Sandra Banda, billing coordinator for David Yardley, MD, PA, in Harlingen, Texas.