Pulmonology Coding Alert

Question: I code for a pulmonologist who recently made the move from a private clinic to large health system. They joined the health system as a pulmonary outpatient provider. When their previously established patients present to the office for an appointment, will the encounters be billed as new or established evaluation and management (E/M) visits?

New Hampshire Subscriber

Answer: You will continue to bill the patients as established patients, using the following E/M codes:

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.)
• 99213 (… low level of medical decision making … 20 minutes must be met or exceeded.)
• 99214 (… moderate level of medical decision making … 30 minutes must be met or exceeded.)
• 99215 (… high level of medical decision making … 40 minutes must be met or exceeded.)

According to the CPT^® guidelines, “An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

So even though the pulmonologist switched locations from a private practice to a large health system, the patients are still considered established to the physician. Payers will also consider the patients established.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC