I have a new patient presenting for an annual visit and a problem visit. Do you code both the problem visit and preventive visit as a new or the preventive visit as a new and the problem as established? I've been hearing conflicting information on this problem and can not find the answer in writing. Can someone help, please?
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Wiki New patient visit
- Thread starter jthomas
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RebeccaWoodward*
True Blue
CPT states (Pg 29 in my book) to select the appropriate office code 99201-99215 for the problem oriented visit. Modifier 25 should be added to the office visit to indicate a significant, separetly identifiable E/M service.
I do recommend that you check with the particular carrier in question. Some carriers do have unique billing guidelines for this scenario.
I do recommend that you check with the particular carrier in question. Some carriers do have unique billing guidelines for this scenario.
mitchellde
True Blue
If you separate this and see it as actually two visits then the way I see it is they were a new patient for the annual then they had to be established for the office. You cannot bill both as new. However Rebecca is correct, you do need to check with the payers on this one and ask if they allow split billing.
Lisa Bledsoe
True Blue
I agree. We code the annual as new and the problerm oriented visit as established.
dmaec
True Blue
*nodding in agreement with Lisa and mitchellde* though we've been down this road before in other forum chats...
others seem to think you can be a new patient "twice".. but,..once you're seen for that "initial" new patient physical or E/M... the next visit (at least the way I read the guidelines)...is established.
we typically code the preventive as a NEW PT, and the E/M as established - documentation supporting both services of course...
others seem to think you can be a new patient "twice".. but,..once you're seen for that "initial" new patient physical or E/M... the next visit (at least the way I read the guidelines)...is established.
we typically code the preventive as a NEW PT, and the E/M as established - documentation supporting both services of course...
kumeena
True Blue
I am confused here .Why one is new and another is established?
New patient one who has not received any professional svcs form th physician or another physician of the same specialty who belongs to the same group practice ,within the past three years
I think it should be both (preventive & office visit) new visit or both established visit
waiting for feedback
Thankyou
New patient one who has not received any professional svcs form th physician or another physician of the same specialty who belongs to the same group practice ,within the past three years
I think it should be both (preventive & office visit) new visit or both established visit
waiting for feedback
Thankyou
The thought is the patient is scheduled for a preventive visit and they meet the definition of a new patient. The preventive visit is done therefore a service has been provided and they are now established. During this visit a problem is discovered and treated. Based on CPT once a face to face service has been provided they are now established, so the probem visit would then be reported as an established E/M.
So you have a new preventive with an established problem visit.
Laura, CPC
So you have a new preventive with an established problem visit.
Laura, CPC
RebeccaWoodward*
True Blue
While I see others point of view....still check with your carriers. UHC plainly states they will pay for a new problem oriented visit with a PE if the patient is indeed new. Below is an excerpt from their policy.
Preventive Medicine services [Current Procedural Terminology ( CPT ® ) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] include annual physical and well child examinations, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine service plus 50% of one of the following problem-oriented E/M service codes only--99201-99205 or 99212-99215--when that code is appended with modifier 25. If the problem-oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.
Preventive Medicine services [Current Procedural Terminology ( CPT ® ) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] include annual physical and well child examinations, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine service plus 50% of one of the following problem-oriented E/M service codes only--99201-99205 or 99212-99215--when that code is appended with modifier 25. If the problem-oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.
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dmaec
True Blue
Laura- NICELY stated - that's how I interpret the guidelines as well.
Thanks Donna!
I am very detail oriented and just looked at the numbers so check this spin on the situation out.
New patient visits require 3 of 3. How do you seperate out the exam elements for the problem and only count the medically necessary ones? Ok say you do that. You will probably be stuck with PF or EPF limiting you to a 99202 or 99201.
If it is an acute problem say sinus infection, it shouldn't be hard to pull enough elements for a detailed history, its a new problem and they get an RX. An established patient would be a 99214, a new patient would be either 99202 or 99201 depending on exam. Reimbursement is higher on a 99214 than the 2 lowest level new patients.
Based on cpts definiton I firmly believe new preventive/est problem is the correct way to code it, I just decided to look at the financial impact today.
Laura, CPC
I am very detail oriented and just looked at the numbers so check this spin on the situation out.
New patient visits require 3 of 3. How do you seperate out the exam elements for the problem and only count the medically necessary ones? Ok say you do that. You will probably be stuck with PF or EPF limiting you to a 99202 or 99201.
If it is an acute problem say sinus infection, it shouldn't be hard to pull enough elements for a detailed history, its a new problem and they get an RX. An established patient would be a 99214, a new patient would be either 99202 or 99201 depending on exam. Reimbursement is higher on a 99214 than the 2 lowest level new patients.
Based on cpts definiton I firmly believe new preventive/est problem is the correct way to code it, I just decided to look at the financial impact today.
Laura, CPC
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dmaec
True Blue
Laura,
that IS interesting! .. even financially it makes sense! BUT - still, finacial impact aside, I still believe (and agree) that based on cpts definiton/guidelines- new preventive/est problem is the correct way to code it.
that IS interesting! .. even financially it makes sense! BUT - still, finacial impact aside, I still believe (and agree) that based on cpts definiton/guidelines- new preventive/est problem is the correct way to code it.
kbarron
Guest
I would be careful to check what the Chief Complaint is. I don't believe that providers can go looking for issues.
I agree completely, this should be the exception not the rule when you have a new preventive appointment.
I am from a rural area originally. Family practice doctors are few and far between. It is not uncommon to wait 2-3 months or longer to get established with one when you are a new patient. We would see this in that situation. They wait 3 months for an appointment and 3 days before they start getting sick, they show up for their well check to get established and mention they have a sinus infection.
Laura, CPC
I am from a rural area originally. Family practice doctors are few and far between. It is not uncommon to wait 2-3 months or longer to get established with one when you are a new patient. We would see this in that situation. They wait 3 months for an appointment and 3 days before they start getting sick, they show up for their well check to get established and mention they have a sinus infection.
Laura, CPC
Karolina
Guru
Here is some food for thought:
I wonder how this case unfolds. Did the patient initially come for the preventative exam and during the course of the visit a problem was discovered and then addressed in the process?
Did the patient come because there was a problem and then it was decided to do the annual while s/he was there since it was about that time of year? Was the patient sent by another provider to continue care at the new practice/facility?
I think in such split cases one must very carefully evaluate all aspects of the specific visit.
I would reach out to the insurance and check what policies/procedures are in place (if any) for such situations.
I wonder how this case unfolds. Did the patient initially come for the preventative exam and during the course of the visit a problem was discovered and then addressed in the process?
Did the patient come because there was a problem and then it was decided to do the annual while s/he was there since it was about that time of year? Was the patient sent by another provider to continue care at the new practice/facility?
I think in such split cases one must very carefully evaluate all aspects of the specific visit.
I would reach out to the insurance and check what policies/procedures are in place (if any) for such situations.
RebeccaWoodward*
True Blue
I just have to ask...I understand you're concept of this encounter; however, how can you ignore the AMA's instructions in CPT?...Not to mention that some carriers DO follow these coding guidelines. I think it's wonderful that we can share our views/opinions but until the AMA changes their guidelines, I will follow their coding conventions........
mitchellde
True Blue
The AMA had an article on their website about 6 months ago or so, which addressed this issue somewhat. In that they talked about the preventive, and oV on the same day. Their take on it was, first you must have two completely separate visit notes, then you may not duplicate any part of the history exam or decision making, the OV must be for something minor that can be addressed in the context of a 99212, because otherwise your patient is too ill to be subjected to a complete physical and is too ill to provide that base line that all other visits are judged against. I also agree with Rebecca regarding the guidelines.
whaleheadking
Guest
I don't see why you cannot have two new visits on the same day, especially when these exams are being done during the same appointment. The guidelines for new vs. established are based on years, and units of service are based on date of service.
The argument for calling the patient established is based on the fact that the provider met him/her at the beginning of the appointment. How long after that did the patient become established? I'm inclined to think the following day based on the guidelines.
The argument for calling the patient established is based on the fact that the provider met him/her at the beginning of the appointment. How long after that did the patient become established? I'm inclined to think the following day based on the guidelines.
Per CPT guidelines professional services are those face-to-face service rendered by a physician and reported by a specific CPT code.
A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group or practice within the past three years.
Where in the guidelines does it state you are new for a whole day? If that same patient is seen at 8am for a yearly and comes back after lunch with possible food poisoning is that 2nd visit new?
Laura, CPC
A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group or practice within the past three years.
Where in the guidelines does it state you are new for a whole day? If that same patient is seen at 8am for a yearly and comes back after lunch with possible food poisoning is that 2nd visit new?
Laura, CPC
dmaec
True Blue
nice point again Laura...
and Rebecca - I see your point of view also, but I don't think anybody is "ignoring" any guideline...it's a matter of interpretation - and I guess I just interpret it that, if you're seen "once" for the intial visit whether that's the preventive service or sick/E/M service - AND then you are seen for something separate and another visit is charged - that second one is no longer "new"...how can it be if you've already been seen, you've now become established...
I know when ever two new visits for the same patient by the same provider and or same specialty different provider have been billed,(here) one is always denied and (no so) oddly the denial reason is because the patient is not considered a "new" patient on that second visit coded.
also - it is rare that there are two visit ..but it does happen.
if you check out page 2 of the CPT 2009 professional edition - AMA - it's very clear in the decision tree ... if you can answer "no" - patient has not received service from the physician or another physician in group or same specialty within the last 3 years - then they are new.
IF that patient has already had a preventive service ("new" based by that decision tree, because they had not been seen before it) how then, for the second "service".. the E/M, (prob/issue) can you answer no to it? using that same decision tree to determine new/est for that visit?, they'd be established, they've already recieved services from that provider
and Rebecca - I see your point of view also, but I don't think anybody is "ignoring" any guideline...it's a matter of interpretation - and I guess I just interpret it that, if you're seen "once" for the intial visit whether that's the preventive service or sick/E/M service - AND then you are seen for something separate and another visit is charged - that second one is no longer "new"...how can it be if you've already been seen, you've now become established...
I know when ever two new visits for the same patient by the same provider and or same specialty different provider have been billed,(here) one is always denied and (no so) oddly the denial reason is because the patient is not considered a "new" patient on that second visit coded.
also - it is rare that there are two visit ..but it does happen.
if you check out page 2 of the CPT 2009 professional edition - AMA - it's very clear in the decision tree ... if you can answer "no" - patient has not received service from the physician or another physician in group or same specialty within the last 3 years - then they are new.
IF that patient has already had a preventive service ("new" based by that decision tree, because they had not been seen before it) how then, for the second "service".. the E/M, (prob/issue) can you answer no to it? using that same decision tree to determine new/est for that visit?, they'd be established, they've already recieved services from that provider
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dmaec
True Blue
mitchellde
True Blue
I agree with Donna, 2nd visit = estb.
RebeccaWoodward*
True Blue
The AMA has this policy in place for a reason. Is it subject to change in the future...maybe/probably....
#1- Our providers are already at the mercy of our carriers edits and their self enforced policies. I , for one (not to suggest anyone isn't ) am a provider advocate. If there is a policy in place that allows a provider to benefit, such as this, I will try within my means to obtain this additional payment. What I mean by this...IF a carrier has an unclear policy regarding this scenario, I am going to fight for that extra revenue. I'm going to point out that the AMA has a guideline in place. As it is now, I can name many, many coding guidelines (even taught to this day by the AAPC) that the carriers manipulate for their benefit yet we become complacent, step aside and say nothing. I am curious about one thing... for those of you whose providers conduct a wellness PE and the patient then presents a problem oriented issue, do you allow the provider to charge for the New PE and a New problem oriented OV? Or...do you offer your opinions, such as those posted on this thread, and reduce their problem oriented visit (w/ provider input of course)...even if your carrier allows both, new, sevices? If so...are those providers aware of what CPT states? My providers certainly are.
#2-For any instructors out there that read this topic, I would really, really like to know what you presently teach your students or what your view is on this topic since the guidelines are there in black and white (or so I think).
I am not trying to sound unreasonable, hostile, etc.... I am, however, tired of justifying my providers coding when there are policies in place that are suppose to be in their favor. My job is to uphold, to the best of my ability, the guidelines that are set forth by the AMA and CMS.
#1- Our providers are already at the mercy of our carriers edits and their self enforced policies. I , for one (not to suggest anyone isn't ) am a provider advocate. If there is a policy in place that allows a provider to benefit, such as this, I will try within my means to obtain this additional payment. What I mean by this...IF a carrier has an unclear policy regarding this scenario, I am going to fight for that extra revenue. I'm going to point out that the AMA has a guideline in place. As it is now, I can name many, many coding guidelines (even taught to this day by the AAPC) that the carriers manipulate for their benefit yet we become complacent, step aside and say nothing. I am curious about one thing... for those of you whose providers conduct a wellness PE and the patient then presents a problem oriented issue, do you allow the provider to charge for the New PE and a New problem oriented OV? Or...do you offer your opinions, such as those posted on this thread, and reduce their problem oriented visit (w/ provider input of course)...even if your carrier allows both, new, sevices? If so...are those providers aware of what CPT states? My providers certainly are.
#2-For any instructors out there that read this topic, I would really, really like to know what you presently teach your students or what your view is on this topic since the guidelines are there in black and white (or so I think).
I am not trying to sound unreasonable, hostile, etc.... I am, however, tired of justifying my providers coding when there are policies in place that are suppose to be in their favor. My job is to uphold, to the best of my ability, the guidelines that are set forth by the AMA and CMS.
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dmaec
True Blue
Morning Rebecca - (not trying to argue either) 
. Yes, my providers are aware of the decision tree for "new vs est"... and yes, they clearly understand that once services are provided to a patient by them, or another provider of the same specialty/group, then that patient is no longer considered "new" UNLESS they haven't been seen within 3 years.
Actually "THIS" is what I was taught in school... by my instructors.
regarding page 29 of the CPT book - (and I think we may have discussed this point before as well)... it says "if the problem/abnormality is signifcant enough to require additional work to perform the key compoentnes of a problem -oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 also be reported. Modifier 25 should be added to the Office/Outpatient code"
it says "appropriate" ..it doesn't say "NEW"...doesn't say "EST"..it says appropriate..
the way I was taught, and the way I see it - if you use what's on page 29 and page 2 - the appropriate code would be an est E/M with a .25 modifier
anyway... I think it's clear by our posts that we all feel pretty strongly in our opinions ...I just wanted to post that yes, my providers know the new/est rules and how it's coded out when on the rare occasions they have a new preventive and an "above/beyond" E/M which is considered est.
NEW INFO.........
however - ! I put a question in to a contact I have (very smart person, I knew she'd point me to a source stating clearly, one way or the other) and she did, to the CPC Assistant October 2006, Volume 15, Issue 10, Page 15 - in where it states the following: (and this is just an excerpt)
Therefore, if preventive medicine services and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (i.e., 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.
goes on to say....
If, however, the acute visit (i.e., office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (i.e., 99211-99215, as appropriate).
so there it is, in black and white (not grey).
I stand corrected! Rebecca THANKS for continuing to post your view! I respect your opinion very much, and that's why I started researching my own understanding of the discussion/debate a bit more.. I'm glad I did! as I said in another post...I'm always learning something new OR being reminded of things I may have forgotten! THANKS AGAIN!!
. Yes, my providers are aware of the decision tree for "new vs est"... and yes, they clearly understand that once services are provided to a patient by them, or another provider of the same specialty/group, then that patient is no longer considered "new" UNLESS they haven't been seen within 3 years. Actually "THIS" is what I was taught in school... by my instructors.
regarding page 29 of the CPT book - (and I think we may have discussed this point before as well)... it says "if the problem/abnormality is signifcant enough to require additional work to perform the key compoentnes of a problem -oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 also be reported. Modifier 25 should be added to the Office/Outpatient code"
it says "appropriate" ..it doesn't say "NEW"...doesn't say "EST"..it says appropriate..
the way I was taught, and the way I see it - if you use what's on page 29 and page 2 - the appropriate code would be an est E/M with a .25 modifier
anyway... I think it's clear by our posts that we all feel pretty strongly in our opinions ...I just wanted to post that yes, my providers know the new/est rules and how it's coded out when on the rare occasions they have a new preventive and an "above/beyond" E/M which is considered est.
NEW INFO.........
however - ! I put a question in to a contact I have (very smart person, I knew she'd point me to a source stating clearly, one way or the other) and she did, to the CPC Assistant October 2006, Volume 15, Issue 10, Page 15 - in where it states the following: (and this is just an excerpt)
Therefore, if preventive medicine services and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (i.e., 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.
goes on to say....
If, however, the acute visit (i.e., office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (i.e., 99211-99215, as appropriate).
so there it is, in black and white (not grey).
I stand corrected!
Rebecca THANKS for continuing to post your view! I respect your opinion very much, and that's why I started researching my own understanding of the discussion/debate a bit more.. I'm glad I did! as I said in another post...I'm always learning something new OR being reminded of things I may have forgotten! THANKS AGAIN!!
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RebeccaWoodward*
True Blue
That's what I love about ya, Donna...gutsy! Yes...we do view this differently. I'm a "matter of fact" kinda gal. If the passage exists, when do you allow a new problem oriented? It would seem never in some of these views. In any case...I like these spicey conversations. Have a good one!
mitchellde
True Blue
Way to go! I had not read that issue either, so we all learned something today, expect for Rebecca who knew it all along! Good going Donna!
RebeccaWoodward*
True Blue
Thank you for posting this, Donna. I, too, respect your comments and views. Between being born in the North and living in the South, I'm often viewed as a big mouth with a hint of southern slang....... Again...this forum is incredible. I hope the AAPC realizes how lucky they are to have you guys!
TWO THUMBS UP!
TWO THUMBS UP!