General Surgery Coding Alert

Question: A patient sees a surgeon in our group practice. Over two years later, the patient returns to the group practice for a new problem but must see a different physician because the original treating surgeon is no longer with the practice. Is this a new or established patient?


Michigan Subscriber

Answer: Under the guidelines set forth by the "three- year rule," the patient is established, not new.

In other words, you cannot bill for a new patient visit just because the patient switches doctors within the group. As long as you are billing under the same provider number, you'll have to stick with the established patient codes (for instance, 99214, Office or other outpatient visit for the evaluation and management of an established patient ...).

In such a case, the "new" treating physician will review the patient's documentation and conduct a full E/M service for the new problem. Although the patient is "new" to that doctor (and may require as much work as a patient who has never visited your group), from a coding standpoint the patient is established. Only if the patient has not been seen in your group for more than three years can you select a new patient service (such as 99204, Office or other outpatient visit for the evaluation and management of a new patient ...).