Professional services: This term can be interchangeable with the term physician services. Professional and/or physician services are face-to-face services, which include office visits, surgical procedures and a broad range of other diagnostic and therapeutic services. These services are furnished in all settings, including physician offices, hospitals, other post-acute care settings and clinical laboratories. For example, suppose the provider reviews a diagnostic image or lab for an inpatient he/she did not actually meet in person and the patient is requested to see the rheumatologist upon discharge. At the visit, the rheumatologist bills a new patient visit because there was no face-to-face encounter during the inpatient stay.
Three-year rule: The general rule for all payers in determining if a patient is new is that a previous, face-to-face service must have occurred at least three years from the date of service. For example, a patient is seen in the office on May 7, 2015. He moves to the other side of town and has recently moved back in the area and makes an appointment with the office to see the rheumatologist on May 8, 2018. Because it has been a full three years since his last date of service, the office will bill this as a new patient visit.
Different specialty/subspecialty with the same group: This area continues to cause confusion when billing for a patient who is seen by different providers within the same group. This goes back to how the practice bills for services. If everything is billed under one tax identification number (especially for group practices), even if a patient is referred to a specialist, this must be billed as an established patient.
Multiple practice sites, same tax identification number: Consider the scenario in which a group practice has multiple sites of care, all billing under the same tax identification number, and each site has their own patient records that are not available at other clinic sites. A patient is a regular at clinic site A, but was sent to clinic site B to be evaluated by a different physician or non-physician provider (NPP) who has never seen the patient and has no records available. Should this patient be coded as a new patient or an established patient? If a patient has been seen in the previous three years by any physician or NPP in the same group and specialty, regardless of which clinic site they went to and regardless of whether patient records are available, only established patient codes should be used. CMS and CPT rules do not provide exceptions to practice sites that do not have access to records.
Get It Right
Although new and established patient visits seem easy enough to distinguish, understanding the definition and coding correctly are vital to a practice’s bottom line. There are important differences between the codes: New patient visit codes (99201–99205) require all three key components (history, exam and medical decision making) to be satisfied in the documentation, although the established patient codes (99211–99215) require only two of the three key components.
