Otolaryngology Coding Alert

Question: An otolaryngologist saw a patient whom our ENT group had never previously treated in the emergency department (ED). During the encounter that we billed as a consultation, the physician told the patient to follow up with an office visit in two weeks.

At the outpatient service, the otolaryngologist performs a full history; a physical; and an ear, nose and throat exam. Should I bill a new patient office visit?


Kansas Subscriber


Answer: No. You should report the outpatient service as an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Why: The patient meets CPT's definition of an established patient. "An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years," states CPT's E/M guidelines.

In your scenario, the otolaryngologist provided professional services to the patient within the past three years - within the past two weeks, to be exact. Therefore, you should bill 99212-99215, not 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...).

The place of service doesn't affect the patient's status. CPT differentiates a new patient from an established patient based on whether the patient received professional services from the physician. The definition doesn't distinguish between locations. So the fact that the first service occurred in the ED and the second E/M took place in the office doesn't impact the patient's status.

Remember: You don't have to determine a patient's status when reporting an ED visit (99281-99285, Emergency department visit for the evaluation and management of a patient ...). Codes 99281-99285 don't distinguish between new and established patients.