Break Down the Established Patient Definition
Question: We bill for a multispecialty clinic, which has a cardiothoracic surgeon, a cardiologist, and a pulmonologist on staff. If a patient sees both the cardiothoracic surgeon and cardiologist, but is new to the pulmonologist, should we report new or established patient office visit codes when the patient visits the pulmonologist? Alaska Subscriber Answer: You will report new patient evaluation and management (E/M) visit codes, such as 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …), if the pulmonologist has not seen the patient within the past three years. Even if the patient has had visits with providers from other specialties in the multispecialty clinic during the three years, you can’t consider the patient as an established patient. According to the CPT® guidelines for E/M services, an established patient must have received services from a provider of the “exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” This means that if the patient is seeing physicians from different specialties within the group in a three-year span, then the patient may be a “new” patient for one physician in a given specialty, even though they have seen a physician from another specialty in the group. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
