Pulmonology Coding Alert

These 5 questions pinpoint patient's status

Take the AMA's advice and answer these five questions to determine definitively if you should treat a patient as new or established for coding purposes.

1. Has the patient ever received any professional services from any physician in this group?

No: The patient is new. Yes: Go on to question #2.

2. Has the patient received any professional service from a particular physician within the past three years, who is now reporting a service?

Yes: The patient is established. No: Go on to question #3.
 
3. Has the patient received any professional service* from a physician in the group of the same specialty, within the past three years?

(*CPT defines a professional service as those face-to-face services rendered by a physician and reported by a specific CPT code.")

No: The patient is new. Yes: Go on to question #4.
 
4. Has the patient received care from a physician of the exact same specialty within the past three years, or is a physician of a different subspecialty now providing care?

The providing physician is of the same specialty: The patient is established.

The providing physician is of a different subspecialty: Go on to question #5.

5. Does the current providing physician have the same tax ID as the physician who provided a separate service within the past 36 months?

Yes: The patient is established.* No: The patient is new.

(*Medicare allows reporting of new patients for physicians in the same group but of different specialties, such as pulmonology and gastroenterology.)

Note: You can also find a similar flowchart on page 2 of the Evaluation and Management (E/M) Services Guidelines portion of the CPT 2007: Professional Edition, published by the AMA.