Part B Insider (Multispecialty) Coding Alert

Published on Sun Jun 11, 2006 PDF

Learn how the 3-year guideline determines what you will report

The timeframe in which your urologist provides services to a patient plays a major role in which E/M codes you will document.

Rule: To determine a patient’s status, use CPT’s established patient definition: “An established patient is one who received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.”

If the urologist has not provided professional services to the patient within the past three years, you should use new patient E/M codes (such as 99201-99205).

If your physician has billed the patient for a professional service in the past three years, you’ll report any subsequent visits as established patient E/M codes (such as 99211-99215), says Beth Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants in Winston-Salem, NC. Professional services that do not involve a face-to-face encounter, such as an x-ray or laboratory tests, do not count toward this rule. The services involved must include a face-to-face service and encounter.

Tip: These guidelines also apply to a new physician in your practice. If the new urologist has provided professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.

Medicare defines “professional services” as any E/M services that is a face-to-face visit. When a urologist provides services to a patient, and another urologist in the same group furnishes services before three years have elapsed, you should consider the patient established.

“If no evaluation and management service is performed, the patient may continue to be treated as a new patient,” according to the Medicare Carriers Manual (MCM) section 30.6.7.

Remember: The rules differ for subspecialties. If your practice has subspecialists, you could potentially have a situation in which you use new patient E/M codes for an otherwise established patient.

If a subspecialist has a specialist distinction that is different from that of the physician/specialists who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient per the June 1999 CPT Assistant, says Stacie L. Buck, RHIA, LHRM, president and founder of Health Information Management Associates Inc. in North Palm Beach, FL. Also, learn how your individual carriers define new and established patient visits with regard to different specialties and subspecialties in the same group, she adds.