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From: The Rheumatologist, March 2012

New Patient vs. Established Patient

by Melesia Tillman, CPC-I, CRHC, CHA

Office visits are considered evaluation and management codes (E/M) in the Current Procedural Terminology (CPT) manual and are a fundamental part of a rheumatologist’s day. There are two types of office visits: new patient and established patient.

There are specific guidelines on the how to determine whether a patient is considered new or established. CPT states, “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.” The manual defines an established patient as “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.” Below are examples of new and established patients:

  • A patient was seen by Dr. Green while he was at another practice. At her next appointment, the patient sees Dr. Green’s associate in Dr. Green’s new practice. Even though the patient has never seen the associate—who is a part of the same specialty—at the new office, the patient would be considered established to the practice.
  • Dr. Brown joins a new practice and treats a patient who was previously seen by another physician in the practice. When Dr. Brown sees the patient for the first time, the patient would be considered an established patient.
  • Dr. Gold joins a multispecialty group and sees a patient that has been seen by another physician of a different specialty. The patient would be considered a new patient to Dr. Gold.
  • Dr. White sees a patient who has not seen anyone in her practice in the last three years; this visit is considered a new patient visit.

Elements of an E/M Visit

An E/M visit consists of seven components:

  • History;
  • Examination;
  • Medical decision making;
  • Counseling;
  • Coordination of care;
  • Nature of presenting problem; and
  • Time.

The first three components are considered the key components when determining the level of an E/M visit—except in the case where time is used—for both an established and new patient visit. The question is, How does the history, examination, and medical decision making determine the level of the visit?

When determining a new patient visit level, all three of these components are required. When figuring out the level for an established patient visit, only two of the three components are needed to determine the level of the visit. Keep in mind that reimbursement is based on medical necessity; therefore, documentation of medical necessity should support the level of the visit.

Examples

The rheumatologist sees a new patient. He takes a comprehensive history and conducts a comprehensive examination; the medical decision making was of moderate complexity. This would be considered a level-four visit because the medical decision making was of moderate complexity; this brought the visit down from a level five.

99204—Office or other outpatient visit for the E/M of a new patient, which requires these three key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of moderate complexity.

99205—Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of moderate complexity.

The rheumatologist sees a patient for a follow-up to a visit six weeks ago. She takes a detailed history, conducts an expanded problem-focused examination, and the medical decision making was of moderate complexity. Because only two of the three key components are needed, the examination is not considered when determining the level of the visit. This established patient visit would be a level four.

99213—Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • An expanded problem focused history;
  • An expanded problem-focused examination; and
  • Medical decision making of moderate complexity.

99214— Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A detailed history;
  • A detailed examination; and
  • Medical decision making of moderate complexity.

The key to compliance is coding all charges correctly. Understanding the guidelines for coding a new patient versus an established patient will cut down on incorrect billing and reduce your denials and appeals. For an in-depth look at time in determining the level of E/M visit, check out “The Dos and Don’ts of Verifying Insurance Benefits” on page 15 of the January 2012 issue of The Rheumatologist.

If you have any questions concerning coding and billing documentation, contact Melesia Tillman, CPC-I, CRCH, CHA, at (404) 633-3777 ext. 820, or mtillman@rheumatology.org.

 


Melesia Tillman, CPC-I, CRHC, CHA, is the coding specialist for the ACR.

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