Difference between 99381 and 99391
A member asked, “In the CPT manual it states that 99381 is an ‘Initial’ and 99391 is a ‘Periodic’ comprehensive preventive exam. How can I tell from the documentation if it is an initial versus periodic exam? Is there certain wording the physicians use to distinguish each exam? Any help please to educate the physicians!”
Another member correctly replies, “The 9938x codes are for new patients; 9939x codes are for established patients.”
Another member agrees with this member’s response and adds, “ … but I always found the wording on this confusing. I mean, you can certainly have an established patient that you are doing an ‘initial’ preventive exam ….”
This prompts another member to ask, “It states in CPT, ‘A new patient is one that has not received any professional services from the physician or any other qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.’ If the doctor sees a newborn patient in the hospital, say for example 99460 or 99461, then sees them in the office (for the first time to the office), and codes 99381, which falls under "new patient," it states in CPT this is allowed. This is confusing to the new patient rule. Can you explain why this is OK?
A member responds, “To the best of my knowledge this is not correct.”
I agree with this member. Unless the newborn was born in the emergency department, where no distinction is made between new and established patients, the baby would be an established patient to the physician after being seen in the hospital.
Another exception would be if the physician didn’t provide a face-to-face service for the baby in the hospital; in which case the baby would still qualify as a new patient in the office.
You may find the December 2016 Healthcare Business Monthly article “How to Determine New vs. Established Patient Status
” on AAPC’s website very helpful.