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New PT Office Visit Vs. New PT Preventive Med

  1. #1
    Default New PT Office Visit Vs. New PT Preventive Med
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    When a NEW patient is seen for their CPE and has a medical problem as well, how would you code the split visit? We were told to bill the 9938X then use establish 9921X-25. Is this correct? Encoder says you can bill both visits as New. I understand that each payor guideline is different, but I just want to know the coding only aspect. Thank you.
    Heather Stefani, CPC

  2. #2
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    Columbia, MO
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    I was always told to bill the preventive as new and the ov as established since now the patient has established care.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    North Carolina
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    Per CPT Assistant....

    Question: If a preventive medicine service (99381-99397) and an office or other outpatient service (99201-99215) are each provided during the same patient encounter to a new patient, is it appropriate to report each evaluation and management (E/M) service as a new patient visit? Or is it appropriate to report the preventive medicine service as a new patient and the acute visit (ie, office or other outpatient service, 99201-99215) as an established patient?

    AMA Comment: It is important to first take careful note of the New and Established Patient instructions provided in the E/M services guidelines of CPT 2006 (page 1). Specifically, the guidelines state:

    Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). 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 past three years.

    An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

    Therefore, if a preventive medicine service 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 (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.

    If, however, the acute visit (ie, 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 (ie, 99211-99215, as appropriate).

    In the past, I've lived by this rule/guideline. Over the last couple of months, my opinion has changed. (I can hear the gasps now...) I find that billing for both, during the same session, presents some hurdles for documentation.

  4. #4
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    Quote Originally Posted by rebeccawoodward View Post
    Per CPT Assistant....

    Question: If a preventive medicine service (99381-99397) and an office or other outpatient service (99201-99215) are each provided during the same patient encounter to a new patient, is it appropriate to report each evaluation and management (E/M) service as a new patient visit? Or is it appropriate to report the preventive medicine service as a new patient and the acute visit (ie, office or other outpatient service, 99201-99215) as an established patient?

    AMA Comment: It is important to first take careful note of the New and Established Patient instructions provided in the E/M services guidelines of CPT 2006 (page 1). Specifically, the guidelines state:

    Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). 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 past three years.

    An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

    Therefore, if a preventive medicine service 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 (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.

    If, however, the acute visit (ie, 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 (ie, 99211-99215, as appropriate).

    In the past, I've lived by this rule/guideline. Over the last couple of months, my opinion has changed. (I can hear the gasps now...) I find that billing for both, during the same session, presents some hurdles for documentation.
    Thank you, (gasp) this information is very helpful. Thanks again.
    Last edited by hstefani; 09-29-2009 at 12:35 PM.
    Heather Stefani, CPC

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