Pulmonology Coding Alert

Tip: Count the years since the patient's last visit before choosing an E/M code

When your pulmonologist provides an office or outpatient E/M service, you can't begin to code his work until you determine if the patient is new or established. If you understand CPT's guidelines, you'll be able to quickly differentiate the two and guarantee proper coding for your physician's work. CPT Provides Clear Definitions The chief factor in determining new or established is time. You need to look at whether your pulmonologist has seen the patient in the past, and if he has, how long ago.

Rule: To determine a patient's status, use CPT's established patient definition: "An established patient is one who 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."

If the pulmonologist has not provided professional services to the patient within the last three years, you should use new patient E/M codes (such as 99201-99205). If your physician has billed the patient for a professional service in the past three years, you'll report any subsequent visits with established patient E/M codes (such as 99211-99215), says Beth Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants in Winston-Salem, N.C.

Professional services that do not involve a face-to-face encounter, such as an x-ray or a pulmonary function test interpretation, do not count toward this rule. The services involved must include a face-to-face service.

Tip: These guidelines apply even to a new physician in your practice. If your new pulmonologist has provided professional services to a patient elsewhere, such as a hospital, within the last 36 months, the patient is an established patient whether this is his first visit to your practice or not. Don't Focus on Location Look at your physician's specialty, time, and tax ID number, not location or insurer, when deciding a patient's status. CPT and CMS guidelines do not vary on the definition of a new or established patient.

Therefore, if a pulmonologist provides professional services to a patient in the hospital, any physician who has the same tax identification number and provides subsequent office or outpatient care must consider the patient an established patient and bill the appropriate established patient office visit code (99211-99215).

The place of service is irrelevant to the new/established patient definition; new or established refers to the patient's relation to the physician(s), not the patient's relation to the office, Janeway says.

Example: A pulmonologist in your group provides an inpatient consult to a 1-year-old child he's never seen before. The patient then comes to your office for follow-up care one week later.

You should report an established patient office visit for the physician's in-office follow-up (99212-99215) because the [...]