How to Manage Denials of Evaluation and Management Coding for New Rheumatology Patients

Evaluation and management (E/M) documentation and coding are not always clear. The E/M codes, a small group of CPT codes written by the American Medical Association (AMA), are the main billing codes for rheumatology practices. More and more practices are seeing denials because the patient is not determined by private payers and Medicare to be “new.” Services are frequently denied or coded down, requiring appeal. (Note: The CPT services referenced in this article are for educational use only. Copyright is held by the AMA.)

Background

Prior to 2012, the definition was much broader and stated, “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.” To date, many insurance carriers as well as many Medicare Administrative Contractors are still using this definition. The new definition and how this might impact push back when E/M claims are inappropriately denied or coded down.

Current Definition

The new and established patient definitions in the E/M guidelines were further revised for CPT 2012, 2013 and 2014, and are present in the 2015 CPT to include important terms such as “exact” and “subspecialty,” as well as “qualified health care professional.” Please reference “New and Established Patient” under the Evaluation and Management (E/M) Service Guidelines in the front of your CPT book.

Based on the revisions made since 2011, subspecialties are now recognized for the determination of established vs. new patients. The revisions further clarify that although the physician or qualified healthcare professional may be of the same specialty, differences among subspecialties might require a new patient workup, rendering a new patient service rather than an established patient service. The following examples provide further clarification for the reporting of these services:

• New patient — A new patient is now defined as one who has not received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years; and
• Established patient — An established patient is now defined as one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

In order to determine if your patient is “new” or “established,” you will need to understand two terms used in CPT’s definition of a new or established patient: professional service and group practice: