Cardiology Coding Alert

Payers reimburse physicians at a higher rate for new patient visits (99201-99205) than for established patient visits (99211-99215), based on the fact that physicians need to do more during an initial visit. For example, a level 3 new patient visit (99203) has been assigned a value of 2.19 relative value units (RVUs), while the same level of visit for an established patient only has 1.20 RVUs.

But, even though you are seeing the patient for the first time, if the patient already has seen another specialist in the same practice, it may not be possible, or even appropriate, for the physician to bill the visit as a new patient.

According to the guidelines set forth in CPT 1999,
a new patient is one who has not 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. This guideline appears straightforward; however, as is often the case when trying to determine the appropriate code for reimbursement, there are factors that complicate the issue for cardiologists.

Not All Medicare Carriers Follow
AMA New Patient Guidelines

For example, cardiologists are often called to read echoes or EKGs, but in many cases they may be unaware of the patients name because the test is identified only by a bar code. Subsequently, the same patient may visit the cardiologist in his office. According to American Medical Association (AMA) guidelines, a test interpretation (e.g., echo or EKG interpretation) constitutes a professional service and thus the patient is now established, even though the cardiologist is seeing the patient for the first time.

But this policy is unfair to cardiologists and other specialists, maintains Terry Fletcher, BS, CPC, CCS-P, a cardiology coding specialist and president of Physician Reimbursement Solutions of Laguna Beach, CA. If cardiologists are unaware of the identity of the patients whose test they interpreted, they may bill a new visit through no fault of their own when one of those patients visits their office, Fletcher says.

She also notes that Medicare differs from the AMA on this issue. According to Fletcher, there is no Medicare policy regarding test interpretations and new visits, and individual and private Medicare carriers have set up their own guidelines, so you need to check with your local carriers about how they interpret this issue. If you can show a strong rationale for billing a new patient visit (e.g., the cardiologist read an unidentified EKG, we didnt even know it was the same patient) even though the cardiologist technically provided a professional service within the last three years, Medicare is unlikely to penalize you, especially if it concurs with the rationale, says Thomas Kent, CMM, principal [...]