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Thread: Pediatric Inpatient/Outpatient

  1. #1

    Default Pediatric Inpatient/Outpatient

    AAPC: Back to School
    I truly hope someone can solve a problem for me. In the hospital I work at no one seems to be sure how it works from inpatient to outpatient and established patient versus new patient. If a baby is born and is a preemie and seen by the neonatologist and then 4 months later the same neonatologist sees the child in the outpatient clinic once again as the neonatologist for another diagnosis such as slow behavioral growth etc how can this be charged? It is the same physician, same hospital just one of the outpatient clinics in the hospital. He says he can charge a new patient the first time,which makes sense. By the way, obviously the first time was inpatient. Then, he says he can charge a consult on the second visit or new patient on the second visit. The way I understand it if you see the same patient within 3 years it is always established regardless and is it even possible to charge a consult ? Sorry to be so wordy but I need to settle this quickly before it is done incorrectly for any length of time.

    Thanks so much


  2. #2


    Per CPT guidelines...
    "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 practice, within the last three years."

    It seems pretty clear that if he provided professional services within the last 3 years it is no longer a new patient even if he is seeing the patient for a different reason. Inpatient/Outpatient should not make a difference. What you describe is a new problem, not a new patient so you are absolutely right about not coding for a new patient. Having said that... if the patient is referred to him for a consult by another physician he can charge for a consult.

    Office or Other Outpatient Consultations do not differentiate between new or established. CPT specifies the guidelines for a consultation... (see the guidelines for consultations in your CPT book just prior to cpt 99241) any follow-up visit however would be coded with the appropriate established patient e/m.
    Barbara Haskins CPC

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default Barbara is absolutely correct

    Barbara is absolutely correct. Any visit after the first visit is an established patient, as long as it falls within 3 years of the first visit.

    EXCEPT, if the baby's pediatrician (or other provider) has requested a consultation from the neonatologist, this might be coded as a consult (depends on documentation).

    F Tessa Bartels, CPC, CPC-E/M

  4. #4

    Default Pediatric Inpatient/Outpatient

    Thank you both very much for your quick reply. No one seems very happy with the outcome, especially the doc charging a consult every visit, but it is better to stay compliant! As for the rest, I guess just deal with each problem as it arises.

    Once again, thank you very much

    Bonnie Roundy, CPC

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