Otolaryngology Coding Alert

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


Michigan Subscriber
Answer: Under the guidelines set forth by CMS- -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 group number, you-ll have to stick with the established patient codes (for instance, 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ..., or, if the visit meets the requirements of a consult, 99241-99245, Office consultation for a new or 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 no physician in the same specialty in your group has seen the patient for more than three years can you select a new patient service (such as 99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...).