Pain Management Coding Alert

Published on Tue Sep 01, 2015 PDF

Question: What is the difference between a new and established patient, for office E/M coding purposes? I’ve heard that you can consider a patient new even if they’ve been to your practice before. Is that true?

Nevada Subscriber

Answer: Quite obviously, if your practice sees a patient for the first time ever, you should choose a new patient E/M code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …). There are also times when you should consider a patient “new” even if she’s been a patient at your practice before.

The chief factor in determining whether a patient is new or established is time. You must decide whether you have seen the patient in the past, and if you have, how long ago. According to WPS Medicare, 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.”

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.

How it works: Let’s say general physicians A and B both work for the same group practice. Physician A performs an office E/M in July 2013 for a patient’s stomach pain. In May 2015, physician B performs an office E/M for the same patient to address her neck pain. For the 2015 visit, you should choose an established patient E/M code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …).

Potential exceptions: 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.