Neurology & Pain Management Coding Alert

2 questions allow you to pick the right code -- and the right level -- every time When reporting many common E/M services, you must know two things: 1. Is the patient new or established? 2. What are the documented levels of history, physical exam, and medical decision-making (MDM)?

Here are quick instructions on how to use this information to select the correct E/M level every time. -3-Year Rule- Determines Patient Status Generally, you should consider a patient to be established if any physician in your group (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. A recent CMS transmittal (R731CP, change request 4032) re-enforces the agency's new/established patient policy.

Don't let different locations lead you astray: If your practice has multiple locations, and a physician in location A sees the patient in January and a physician at location B sees the patient the following December, the patient is still established. The need to create a new chart is inconsequential, Hammer says.

Example 1: A primary-care physician recommends that a 60-year-old female see a neurologist for numbness and tingling in her right arm. One of the other physicians in your group interpreted some test results for the same patient last year but provided no face-to-face service. In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years, says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, Fla.

Example 2: A patient comes to your office complaining of constant head pain. Although this is physician A's first time meeting the patient, physician B, in the same group practice, saw the patient two years ago for a similar complaint.

In this case, you should consider the patient as established.

Exceptions Could Occur for Different Specialties The new patient rule applies when physicians in the same practice are also of the same specialty, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders- National Advisory Board.

In a nutshell: If your practice is big enough and covers enough specialties, two physicians may see a patient for completely different reasons, Parman says. This could allow you to report a new patient visit (or an initial consult) even though two physicians in the same practice saw the same patient within a three-year period.

Example: A general neurologist in your neurology practice sees a patient in 2004 [...]