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.