Otolaryngology Coding Alert

Question: Is a patient a new or an established patient when a physician in one specialty transfers the patient to a physician in a different specialty, and both physicians are under the same tax identification number?


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Answer: In this scenario, you should count the individual as a new patient. The CPT definitions for new and established patients refer to services that physicians in the same specialty render. When a physician transfers a patient within the group practice to a physician in another specialty (not sub-specialty), you should consider the patient a new patient. 

Example: A general surgeon refers a car accident patient with facial trauma (905.0, Late effect of fracture of skull and face bones) to an otolaryngologist in the same surgical group practice. The otolaryngologist who has never rendered services to the patient treats him in the office.

You should report a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...). Even though the general surgeon and the otolaryngologist are in the same group practice, they are in different specialties. So the patient is new to the otolaryngologist.

Watch out: Patients referred to a sub-specialist are considered established, unless the sub-specialist has a different tax identification number.

Example: An otolaryngologist refers a patient with chronic serous otitis media (381.1x) to the pediatric otologist in the same ENT group. Because the pediatric otologist is not in a different specialty, but is instead a sub-specialist, you should consider the patient an established patient. So you would report an office visit with 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).