Pulmonology Coding Alert

Question: An insurance representative recommended at an in-house seminar that if our pulmonologist sees a patient in the hospital, we can still bill that patient as "new patient" if we later see him in the office. But when one of our pulmonologists treats a patient in the hospital whom he later sees in our private practice, I've been considering that patient to be "established." Who is correct?


New York Subscriber

Answer: You are correct. CPT defines a new patient as "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." Any patient who has received care within the past three years is "established."

Show the insurance representative CPT's new and established patient definitions under the heading "Definitions of Commonly Used Terms" in the Evaluation and Management Services Guidelines. The representative may be unfamiliar with in-office coding that follows this rule.

A patient's status doesn't affect hospital care coding. For instance, you report initial hospital care with 99221-CPT 99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) and subsequent hospital care as 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...), regardless of whether the patient is new or established.

But if one of your pulmonologists treats a patient in the hospital and later (within three years) treats the patient in the office, you must code the encounter as an established patient E/M service, such as 99212-99215 (Office visit for the evaluation and management of an established patient ...).