Cardiology Coding Alert

Navigating Between New and Established Patient Codes Can Increase Reimbursement

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 of Kent Medical Management in Maryland and a former practice manager.

Note: If the cardiologist, after reading a stress echo or EKG, contacted the patient and asked him or her to return to the office, an established patient E/M code would have to be used.

Kent says that the AMA guidelines are too conservative but argues that in the absence of a written Medicare policy, AMAs guidelines are irrelevant, at least for Medicare patients. If the AMA says something that doesnt make sense but HCFA does not say it, it doesnt matter what the AMA says, because HCFA is the payer, he says.

Because there are no definitive Medicare guidelines on the issue, Kent says private payers may or may not follow AMA rules. If a private payer rejects a new patient visit because the physician previously interpreted a test, the denial should be appealed and the payers written policy on these matters should be requested, he says. However, should the request yield a policy explicitly based on the AMA guidelines, or if such as a policy is written in the managed-care contract, the appeal should be concluded.

Subspecialties Within the Same Practice

If a patient who has already seen a cardiologist in your practice 18 months earlier returns to see a subspecialist (for example, an electrophysiologist) about an unrelated issue, should that patient be considered new or established? An informal sampling of coders and coding consultants reveals mild differences of opinion about the issue.

For example, a patient is referred to a cardiology practice for an undifferentiated type of chest pain. A general cardiologist performs an examination and prescribes medication for the patient, who responds well and is asymptomatic. The patient continues to visit the same cardiologist once a year. Two years later, however, the patient begins to have runs of paroxysmal atrial tachycardia (PAT), and is referred by his internist to an electrophysiologist who also belongs to the practice.

If the patient is covered by Medicare, there are some seemingly conflicting guidelines to sift through, says Georgeann Edford, RN, MBA, president of Coding Compliance Solutions, a physician reimbursement consulting firm in Birmingham, MI. She points out that although Medicare regulations state that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician, the guidelines also say that physicians in the same group practice but who are in different specialties must bill and be paid without regard to their membership in the same group.

According to Edford, the issue boils down to whether Medicare recognizes subspecialty designations. If you look at the Medicare-approved specialties, there is no provision for subspecialties, so all the cardiologists in the practice have the same Medicare classification, she says.

Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., NJ, agrees. A lot of people believe that if the patient goes to a different subspecialist, the visit can be billed as a new patient, but that is not true, she says.

The key to billing in this situation, Brink maintains, is the tax identification number. Typically, specialists in the same practice use the same ID number, so if a patient of one cardiologist sees another cardiologist in the same practice within three years, regardless of subspecialty, that second visit would have to be billed as an established patient visit, she says.

Although some coders believe that if the subspecialist has a different Medicare-designated specialty code, the visit can be billed as a new patient, Brink says that is not the case.

Kent, meanwhile, acknowledges that earlier Medicare guidelines stated that CPTs three-year threshold applied to any doctor in a group practice, regardless of specialty, but he asserts that Medicares revised regulations now allow physicians to be differentiated by specialty.

In effect, the revision gives local Medicare carriers discretion over whether to allow specialists (and subspecialists) within the same group practice to bill a new patient visit in such circumstances, so coders should check with their local Medicare carriers to get their definitive view on the issue.

Brink and Kent agree that if the subspecialist has a different tax ID number, which sometimes occurs even if he or she is operating under the umbrella of the same
cardiology practice, then the visit to the second doctor can be billed as a new patient visit.

Fletcher, meanwhile, notes that the intent of the new patient visit designation was to compensate the physician for the workup of a new patient. If the subspecialist works in the same practice as another physician the patient has seen, and all the subspecialist (or different specialist, for that matter) does is pull the patients chart, the rationale for the added first visit compensation no longer applies. In other words, even though physicians with different tax numbers or in different specialties may be able to bill for a new patient visit, the intent of the guideline has been breached.

Visit May Qualify as a Consultation

Although the scenario involving the general cardiologist and the electrophysiologist described above would have to be billed as an established patient visit, there are similar situations that reimburse at a higher rateif they meet the qualifications for a consultation.

For example, if the general cardiologist in a practice sent the patient to the electrophysiologist directly (or if the internist outside the practice requested the visit), the electrophysiologist could bill for a consult, as long as the requirements for such a visit were met and documented. These requirements include:

- a written request for an opinion or advice by the requesting physician;

- the request must be documented in the patients record;

- a written report from the consulting physician to the requesting physician; and

- complete care of the patient was not transferred to the consulting physician

Of course, if the consulting physician took over the treatment of the patients paroxysmal atrial tachycardia, subsequent visits would be billed as established patient visits.

Note: Consultations, unlike office visits, do not distinguish between new and established patients.

Finally, Cynthia Swanson, RN, CPC, a management consultant with Seim, Johnson, Sestak, Quist, LLP, an accounting and healthcare consulting firm in Omaha, NE, notes that the reimbursement software used by Medicare carriers contains edits and audits that flag new patient visit codes. According to Swanson, Medicare monitors these codes for excessive and inappropriate use, so if new patient categorization of visits is used overzealously, there could be a high price to pay in the future.