Part B Insider (Multispecialty) Coding Alert

Published on Wed Oct 12, 2005 PDF

After three years, familiar faces are new again

Heads up: The Centers for Medicare & Medicaid Services tweaked some of the rules for evaluation and management coding in a new transmittal (731), dated Oct. 28.

For example, CMS clarified the definition of “new patient” for E/M coding. Experts say the policy hasn’t really changed, but CMS is explaining it differently, and it can provide a useful refresher course. According to CMS someone is a new patient if none of your physicians have seen her face-to-face in the past three years.

In other words, if one of your physicians interpreted a patient’s test results or did some other non-face-to-face service in the past three years, you can still consider that person a new patient the next time she comes into the office, according to consultant Devona Slater with Auditing for Compliance & Education in Leawood, KS.

“Many times, our physicians don’t realize they can use a new patient code if they haven’t seen the patient in 36 months,” says Robyn Brooks with Lee-Brooks Consulting in Chicago.

Also, CMS says it won’t pay for any E/M services on the same day by physicians in the same practice and same specialty--unless you document that the visits were for unrelated problems. Sometimes carriers won’t pay for same-day E/Ms even when they’re for unrelated problems, but CMS is telling the carriers to pay for repeat visits. (See PBI, Vol. 6, No. 37.)

Finally, CMS says you can’t bill for a level one E/M service (i.e., 99211) on the same date as a drug administration service such as infusion--even if you use modifier 25. Billers sometimes mistakenly bill for 99211 on the same date as a drug administration code, notes Slater.

A physician or non-physician practitioner would need to see a patient on the same date as a drug service to be able to bill for an E/M visit, Brooks explains--and that E/M service must meet a higher complexity level than 99211.