Practice Management Alert

Specialty codes can clarify multispecialty confusion

You might think you can easily differentiate between new and established patients, but the choice is not always black and white - especially in the multispecialty world.
 
If a physician sees a patient who is already established under another physician in your practice, the medical specialties involved will determine whether you bill that patient visit as new or established. But before making that determination, you must understand the rules governing when to bill a new or established patient.
 
Brand-new patients: You should bill a new patient when the physician has "never before performed a face-to-face service on the patient" that you could report with a CPT code, says Shannon O. Smith, CRTT, CPC, consultant auditor with Doctors Management in Knoxville, Tenn. Phone calls, record reviews and other non-face-to-face services do not count as a new patient service.
 
Place doesn't matter: The location of patient encounters can vary, but the patient is not new if the physician rendered a face-to-face service in the past, says Terri Fischer, CPC, CMC, manager with LarsonAllen Health Care Group in St. Louis, Mo. For example, a new patient visit occurs in the hospital, and the same physician then treats the patient in the office. You would report that office visit as an established patient visit.
 
Time's up: You should also bill a new patient whenever the physician has not treated the patient "within a three-year time frame," Smith says.
 
Bill established: You should bill an established patient visit if the physician "has billed any type of face-to-face service on the patient" within the past three years that you could report with a CPT code, Smith says.
 In addition, if a new physician joins your practice, you should bill established patient visits for any patients who follow him to your practice. Although a patient may be new to your practice, she is not necessarily new to the treating physician.
 
Don't be fooled: Disagreements about this policy sometimes arise if the new physician can't obtain the patient's medical record from his last practice, Fischer says. If the physician has to reconstruct the record, some billers argue that the visit is a new patient. Not so, most carriers and coders agree.

Know the Multiphysician Catch

Suppose a patient sees one physician, and then on a later date sees a different physician within the same practice. You can only bill a new patient visit for the second encounter if the two physicians are of different specialties, and the patient sees the second physician for a specialty-specific reason, Fischer says.
 
For example, an internist (specialty code 11 - see section at right) may treat a patient with heart disease, and then recommend the patient continue his care with a cardiologist (specialty code 06) in the same practice. The patient's first encounter with the cardiologist would constitute a new patient visit if the cardiologist assumes the patient's care (and doesn't just render a consultation).
 
Exception: If a new physician sees a patient because he has better appointment availability, is doing on-call work or is filling in for a vacationing physician - not because of the nature of his specialty - bill an established patient visit.
 
Real-life scenario: "Our orthopedist was called to Iraq, and our physiotherapist is going to see all his patients while he's gone," Smith says. The physiotherapist will be treating these patients by default, not because of the nature of her specialty, so these encounters will be established patient visits, she says.

Check Out CMS Specialty Codes

CMS provides a list of specialty codes to define which specialties qualify as truly separate for purposes of new patient reporting.
 
Action tip: If you are a multispecialty practice, check the CMS listing of specialty codes (online at www. cms.hhs.gov/providers/enrollment/taxonomy.pdf) to see which of your
specialists may bill a new patient visit when they see a patient who is already established under another doctor in the practice. If the physicians fall under different specialty codes, chances are good you'll be able to bill a new patient visit.
 
Example: Consider code 06 for cardiology and code 78 for cardiac surgery. These specialty codes indicate that if a cardiologist sees a patient and then sends him to a cardiac surgeon within the same practice, the cardiac surgeon can bill the appropriate-level new patient E/M code.
 
Trap: If you are an internal medicine practice with different specialists, Medicare must list your specialists under their specific specialty codes in order to recognize them as separate. You may have a cardiologist and gastroenterologist, but if they are all listed as specialty code 11 (internal medicine) you cannot bill a new patient visit when a patient switches from one physician to another.