By Alexander Miller, MD, April 01, 2015
Intuitively, one will have formed a concept as to who constitutes a new patient, who is empowered to evaluate the patient and bill individually for that evaluation, and how medical records should support the level of billing. However, what criteria should one follow? The Current Procedural Terminology (CPT) and Medicare provide specific guidance.
A new patient is one who has not received any services from a physician or qualified non-physician practitioner — or, in a multispecialty group practice setting, from any physician of the same specialty and subspecialty — for the preceding three years. The corollary is that if the patient has received services by any of the above individuals for the preceding three years, that patient is defined as an established patient. Note that whether the presenting problem is new or ongoing has no bearing upon the new patient/established patient decision making. The essence is whether the patient is new to the physician/qualified non-physician practitioner, and whether the patient had been previously evaluated by a group practice physician of the same exact specialty/subspecialty within the preceding three years.
Who are the individuals empowered to individually provide evaluation and management services? They are state-licensed professionals practicing within their scope of practice and fulfilling the practice and license requirements as set forth by their individual state’s laws:
- Physicians (MD, DO)
- Nurse practitioners
- Certified nurse midwives
- Physician assistants
The level of the evaluation and management service provided is determined by three principal features: history, examination, and medical decision making. For a detailed review of the criteria utilized for determining levels of service provided, see the Medicare Learning Network document “Evaluation and Management Services Guide."
Example 1: A patient is assigned to see you in your multispecialty group practice for an evaluation of a diffuse rash that may be allergic in nature. She has already been evaluated by an allergist in the group two weeks prior, but is new to you, the dermatologist. You do an appropriate evaluation and, as she is a new patient to you, you bill CPT 99203 for the new patient evaluation.
Answer: Correct. Although the patient was previously evaluated and treated by a physician in the group practice, you may bill for a new patient E/M code, as the patient is new to you and you are of a different specialty/subspecialty than the allergist. Commercial insurers may handle the billing in their own proprietary manners, distinct from Medicare. Be aware of your individual private payer’s handling of such claims.
Example 2: You are in dermatology group practice. A patient new to you comes in for an evaluation of an established problem. She was last evaluated two years ago by a dermatologist who has since left the practice. As the patient is new to you, you bill for an appropriate level of E/M new patient service, CPT 99202.
Answer: Incorrect. The patient received care from a same-specialty physician in the group practice within the preceding three years. The group practice identifier and the less-than-three-year time interval between visits determine the new versus established patient status. The fact that the previous practitioner has left the practice has no bearing upon the visit type determination.[pagebreak]
Example 3: After several years working in a group practice you decide to leave the practice to join another group miles away. A patient whom you had cared for in the first group trails after you and sees you for a new problem evaluation 2 ½ years after you had last cared for him/her in the preceding group practice. The patient fills out new patient information, including a new patient history and review of systems, and is entered into the new group practice’s records. As the patient is new to your group practice, you bill CPT 99203 for the level of E/M provided.
Answer: Incorrect. The definition regarding new versus established patient status does not mention practice setting as a determinant for new versus established patient status. Rather, an established patient is one who “has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” (CPT 2015) In this case, although the physician has moved to an unaffiliated, separate group practice, he/she had cared for the patient within the preceding three years. Consequently, although the practice location had changed, the patient is not considered new to the treating physician, and the office visit must be billed as an established patient E/M: CPT 99212-99215. Furthermore, the absence or availability of the patient’s medical records from the previous practice does not influence the new versus established patient decision making.
Example 4: You, the dermatologist, are in a multispecialty group practice. A Medicare patient whom you had evaluated in the preceding three years comes in to be evaluated in your absence with a new problem and is seen by a nurse practitioner (NP) who works with another dermatologist in the large practice. As the patient is new to the nurse practitioner, the visit is billed under the NP’s identifier as a new patient E/M (CPT 99201-99205) and the practice is reimbursed at 85 percent of the Medicare fee schedule.
Answer: Incorrect. The nurse practitioner is considered to be an extension of the specialty/subspecialty of the physician with whom the NP works. In this case, the NP works with another dermatologist in the practice. Therefore, as the patient had been seen by a dermatologist in the practice in the preceding three years, the visit is considered to be an established patient visit. The CPT supports such an interpretation: “When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician.”
Example 5: Your dermatology practice is covering for an outside dermatology practitioner during his/her absence. A patient who was last seen one year ago by the absent dermatologist is referred from the absent practitioner’s office for evaluation of a new problem. You have the patient fill out a new patient data form, treat the patient, and bill for a new patient visit, CPT 99203.
Answer: Incorrect. Although you have never before seen this patient, the encounter is treated as it would be if the patient were seen in the covered dermatologist’s office. Since the patient last saw the absent dermatologist within the preceding three years, you must bill for an established patient visit.
Example 6: You are a Mohs surgeon. A patient new to you is referred by one of your group practice’s general dermatology colleagues. You evaluate the patient, determine an appropriate need for Mohs surgery, and schedule the patient for surgery. Although your Mohs surgery subspecialty is distinct from the referring physician’s general dermatology specialty you bill an established patient visit, CPT 99213.
Answer: Correct. Although the patient is new to the Mohs surgeon, he/she is not new to the practice, which is defined by the group practice NPI and Tax ID number. Medicare will adjudicate your claim submission based on your primary specialty taxonomy code, NPI, and Tax ID number. Subspecialty categories of practice that have different taxonomy codes under the NPI, such as general dermatology and Mohs surgery, do not clearly determine primary subspecialty status. In order to be able to bill for this scenario as a new patient encounter, your primary specialty must be listed as Micrographic surgery — taxonomy code 207ND0101X — in the Medicare database to distinguish the difference in expertise that allows for you to bill the new patient encounter code. Commercial payers, on the other hand, do not have the capability of identifying primary and/or subspecialty taxonomy codes. In this case, the encounter will be adjudicated based on the group practice NPI and Tax ID number, hence an established patient code would be appropriate.