Pain Management Coding Alert

Reader Question:

3-Year Rule Tops New/Established Px Concerns

Published on Wed Nov 08, 2017

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Question: What is the difference between a new and established patient when reporting evaluation and management (E/M) services?

Ohio Subscriber

Answer: You'll code for new patients with CPT^® codes 99201 (Office or other outpatient visitfor the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) through 99205 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity ...), depending on encounter specifics.

For established patient E/Ms, you'll choose from the 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional ...) through 99215 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) code set, depending on encounter specifics.

(Note: These new and established patient parameters are for Medicare payers, and private payers that follow Medicare's rules. If you have any doubt as to a patient's status with a non-Medicare payer, check with a rep before filing the claim.)

New Px parameters: So, if the practice is seeing the patient for the first time ever, choose a new patient E/M code. Don't automatically assume that all the patients your practice has seen before are automatically established, though; there are times when a patient is considered "new" even if she's been a patient to your practice before.

WPS Medicare states that a new patient "has not received any professional services from the physician within the previous three years. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."

So, let's say a patient reports to your Medicare PM practice complaining of shoulder pain on November 21, 2017. Records indicate that the patient last reported to your practice for pain related to a fractured thumb on April 24, 2012. This patient is new, for E/M coding purposes.

Established Px parameters: For coding purposes, an established patient "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 WPS Medicare.

Let's say PM physicians A and B both work for the same group practice. Physician A performs an office E/M in July 2015 for a patient's stomach pain. In November 2017, physician B performs an office E/M for the same patient to address her neck pain.

For the 2017 visit, you should choose an established patient E/M code.

Exceptions: There are a few new and established patient exceptions, which will depend on your practice's scope and the payer. If your practice includes sub-specialists, and the payer allows it, situations might arise in which new patient E/M codes are appropriate for an otherwise established patient.

Best bet: Look before you leap. Contact your payers and ask how they apply new and established patient guidelines – specifically with regard to different specialties and sub-specialties in the same group practice.