Medicare Compliance & Reimbursement

Tip: Keep track of timelines.

Evaluation and management of a patient differs depending on whether your physician is seeing a new or an established patient. And the 3-year rule only complicates matters by requiring you to determine whether a patient has been previously seen by another provider belonging to the same practice and specialty in the last three years.

See what the experts have to say about when you will need to code 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) rather than 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) even if your physician is seeing a patient for the first time.

Turn to CPT^® for Guidance

The chief factor in determining whether a patient is new or established is time, and you must decide whether your provider has seen the patient in the past, and if he has, how long ago.

Rule: CPT^® clearly defines what qualifies as an established patient: “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.”

Ask yourself, “Has the patient seen the provider in the past three years?” Here’s how to code based on your answer:

·         Yes: If your provider has billed for a professional service in the past three years for a patient, you’ll report any subsequent visits using established patient E/M codes (such as 99211-99215), says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

·         No: If your provider has not seen the patient within the past three years, you can report a new patient E/M code (such as 99201-99205), instructs Christy Shanley, CPC, CUC, administrator for the University of California, Irvine department of urology.

Don’t Assume a New Provider New Patient Means

If the patient has been seen before within the same practice, even though he switched doctors, he is an established patient.

If you are in a group physician setting, under the same tax ID, you have to determine if the patient has seen any of the doctors (of the same specialty) — and when — before you can decide on a new or established patient code.

Example: An internist in your practice provides an initial inpatient consultation to a patient he’s never seen before. The patient then comes to your office for follow-up care one week later, but sees a different internist because the first provider is unavailable. You should report an established patient office visit for the physician’s in-office follow-up. Even though the patient has never been to your office, and the second physician has never seen the patient, you should report an established patient code. The patient is an established patient because a physician in the same specialty and group provided professional services within the past three years.

Exception: The rules differ for subspecialties. If your practice has sub-specialists, you may have a situation when you should use new patient E/M codes for an otherwise established patient. Check with your individual payers to see how they define new and established patient visits with regard to different specialties and sub-specialties in the same group.

CPT^® 2012 clarified the definition stating, “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” The portions of the description that were new for 2012 are underlined.

What this means to you: If your practice employs various subspecialists, CPT^® now makes it clear that you can bill claims for patients who see different doctors with different subspecialties using a new patient code [such as 99201-99205], according to Peter A. Hollmann, MD, chair of the CPT^® Editorial Panel, during the CPT^® 2012 Annual Symposium in Chicago.

Avoid Coding Based on Location

You should not use place of service (POS) as an indication of new versus established patient. Based on CPT^®’s established patient definition, new versus established refers to the patient’s relationship to the physician, not his relationship to the practice or its location.

“POS is irrelevant,” Shanley says. Even if your physician saw a patient in the emergency room rather than in your office, the next time your provider or one of his associates sees that patient he is an established patient.

Guideline: If a physician provides professional services to a patient in the hospital, all of his partners (physicians), with or without the same tax identification number, who provide subsequent office or outpatient care must consider the patient an established patient and bill the appropriate established patient office visit code
(99211-99215).

Pay Attention When Physicians Change Practices

All of these new versus established patient rules also apply to a new physician in your practice. If the new provider has provided 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.

If a patient’s doctor leaves the practice but the patient starts seeing another doctor within that practice, the patient is still established because the physicians (assuming they’re in the same specialty) use the same tax ID, Boone says. And if that patient follows the doctor to a new location, s/he is still an established patient. To determine new or established patient payments, insurers will look at the provider’s National Provider Identifier (NPI), not where the service was provided.