Orthopedic Coding Alert

Question: One of our surgeons has subspecialty credentials for elbow to finger procedures. If he sees a patient for an ankle problem, then sees the same patient the next year for a wrist  problem, how do we classify the patient?

Oregon Subscriber

Answer: Consider the patient "established" and report office visits with the appropriate choice from 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Remember: A patient's status doesn't change just because she sees your physician for a different complaint (or for a different area of his specialty). If the physician sees her within a three-year window for any problem, consider her an established patient. If she goes longer than three years between visits, you can classify her as a new patient at her first visit and choose from 99201-99204 (Office or other outpatient visit for the evaluation and management of a new patient ...). Any other visits will fall under the established patient codes.

Exception: The patient's "established" versus "new" status could change if she sees another physician in a different subspecialty of your group. For example, a patient could visit one of your general orthopedists because of an ankle fracture.

If she returns a year later and sees your group's hand specialist for another problem, the hand specialist could consider her a new patient and you could code accordingly.

-- Reader Questions and You Be the Coder were reviewed by Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC; and Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.