Pediatric Coding Alert

Question: A pediatrician is new to our practice from another practice in town. Some of her patients have followed her from her previous practice to our practice. Should I bill the patients as a "new patient" on the basis that they are new to this practice and group number, or should I bill a visit as an "established patient" because the provider saw the patient at her old practice?


Colorado Subscriber
Answer: You should bill as established patient visits (99211-99215) any patients whom the pediatrician saw at her previous practice within the past three years and now sees at your practice for the first time. The CPT new/established patient definition applies to the physician-patient relationship, regardless of location.

"A new patient is one who has not 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," according to the E/M services guidelines.

Although the patients you describe are coming to your office for the first time, the transferring pediatrician has already provided services to them, and thus you should consider the patients "established." The italicized portion of the above new patient definition also means that if another pediatrician within your group sees the patient at your office before the joining pediatrician does, the patient is still established. Because one physician of the same specialty in your group has seen the patient within three years, the patient is established, regardless of whether that pediatrician has previously treated the patient.

CPT's definition is based solely on whether a patient has received professional services from any of the practice's physicians within the past three years. Using a different identification number doesn't change the relationship. Although the pediatrician was not part of your practice when she first established care with the patient, your practice does not get to reclaim the patient as new, meaning new to an identification number.

"Whether the patient has transferred his or her medical records to your office and how long you may have had those records is irrelevant," writes Emily Hill, PA-C, in "Understanding When to Use the New Patient E/M Codes" (FPM Vol. 10, No 8). Even if you have to create the above patients' paperwork and charts for the first time at your practice, you should not consider them "new."