Primary Care Coding Alert

Although CPT defines new and established patients under Definitions of Commonly Used Terms, there are some instances when using one instead of the other is not so evidentnewborns, different doctors, new practices and emergency room visits can confuse coders. CPT states, 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. On the other hand, An established patient is one who 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. In the instance where a physician is on call for or covering for another physician, the patients encounter will be classified as it would have been by the physician who is not available.

Kent Moore, manager of healthcare financing and delivery systems for the American Academy of Family Physicians, emphasizes the key points to consider when determining if a patient is new or established: Have you seen him or her before? How long has it been since you have seen the patient? Has the patient been seen by another physician in your practice? Is that physician of the same specialty or of a different specialty?

Several scenarios help clarify some potentially confusing situations when determining if a patient is new or established.

Scenario #1: The family physician (FP) sees a newborn in the hospital and would code 99431 (history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records). Several weeks later, the baby has a bad cold and the mother brings her to the FPs office for a checkup. Now the patient is considered established, says Jean Ryan, CPC, billing compliance analyst for MeritCare Health System in Fargo, N.D., even though the baby has never been to the office before this visit. Thus, the FP would code 99212 (office or outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; and straightforward medical decision-making).

Scenario #2: A 50-year-old established female patient makes an appointment to see her FP but when she arrives for the visit, the physician is delivering a baby. Instead, she sees another FP in the group practice. Even though its a different doctor, its still the same specialty in the same practice, so she is considered an established patient. The codes 99212-99215 (office or outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: ranging [...]