U nderstanding W hen to U se the N ew Patient …

1 September 2003!w w a f p . org/f pm!F A MI L Y P R A C T I C E MA N A G E ME N T!3 3 ILLUSTRATION BY JOYCE HESSELBERTHNew Patient visits used to be easy todistinguish from those with estab-lished patients . A new Patient wassomeone you had not previouslyseen or perhaps someone for whom you didnot have a current medical record. Today,like so many other aspects of health caredelivery, differentiating between new andestablished patients and coding your servicesaccordingly has become more complex. By CPT definition, a new Patient is onewho has not received any professional servicesfrom the physician, or another physician ofthe same specialty who belongs to the samegroup practice, within the past three years. By contrast, an established Patient has receivedprofessional services from the physician oranother physician in the same group and thesame specialty within the prior three distinction between new and estab-lished patients applies only to the categoriesof evaluation and management (E/M) servicestitled Office or Other Outpatient Services and Preventive Medicine Services, but as afamily physician, most of the codes you sub-mit fall into these categories, and the defini-tion is hard to incorporate into your codinghabits.

2 This article will explain why the differ-ence matters and describe an approach youcan use to make the definition easier to apply. The key differencesThe reason for learning to distinguish newpatients from established patients , apart fromfollowing coding guidelines, is that it enablesyou to be reimbursed for the additional workthat new Patient visits require (see Docu-mentation requirements on page 34). For the new Patient codes, the requiredcomponents and the relative value units(RVUs) are greater than for establishedpatient codes at the same level (see Officevisit RVUs on page 35). So in some cases,not distinguishing new patients from estab-lished patients amounts to shortchangingyourself. For example, a visit that produces adetailed history, detailed exam and decisionmaking of low complexity qualifies as alevel-IV visit if the Patient is established anda level-III visit if the Patient is new. Theestablished Patient visit amounts to ($ ), while the new Patient visitamounts to RVUs ($ ).

3 Another important difference betweenthe codes is that the new Patient codes(99201-99205) require that all three keycomponents (history, exam and medicaldecision making) be satisfied, while theestablished Patient codes (99211-99215)require that only two of the three key Emily Hill is president of Hill& Associates, a national healthcare consulting firm specializingin coding and compliance forphysician practices. Conflicts ofinterest: none Hill, PA-CEven an old Patient can be When to Usethe New Patient E/M Codes3 4!F A MI L Y P R A C T I C E MA N A G E ME N T!w w w. a a f p . org/f pm!September 2003components be satisfied. Because the criteriafor coding problem-oriented new Patient vis-its are more stringent, there are also caseswhere the same service components wouldyield an established Patient code with moreRVUs than the appropriate new Patient example, a visit that includes an expand-ed problem-focused history, detailed prob-lem-focused exam and moderate complexitydecision making would qualify as a level-IInew Patient visit ( RVUs) but a level-IVestablished Patient visit ( RVUs).

4 Problem-oriented encounters for bothnew and established patients can also becoded based on the total time spent with thepatient if counseling/coordination of careconstitutes more than 50 percent of the totalencounter time. The times associated withthe new Patient services, however, are higherthan for the established Patient encounters.(See Time Is of the Essence: Coding on theBasis of Time for Physician Services, FPM,June 2003, page 27.) Preventive medicine encounters all requirea comprehensive history and exam, and thecodes are selected according to the age of thepatient. The RVUs vary according to the levelof physician work associated with performingcomprehensive evaluations for the different ageranges (see Preventive visit RVUs on page 35).Defining professional services Varying interpretations of what constitutes a professional service have been a source ofconfusion for practices trying to determinewhich patients qualify as new. CPT 2001 clar-ified the matter by defining professional ser-vices as those face-to-face services rendered bya physician and reported by a specific CPTcode(s).

5 The key phrases are face-to-face and reported by a specific CPT code(s). Suppose you provided the interpretationof an ECG for an inpatient you did not actu-ally meet in person. When you see thepatient in your office (assuming this occurswithin the next three years), you wouldreport the E/M service you provide using aA new Patient has notreceived any profes-sional services from thephysician, or anotherphysician of the samespecialty who belongsto the same grouppractice, within thepast three years. Only the office visit and preventive medi-cine codes differentiatebetween the new andestablished requirements andthe reimbursement aregreater for new new Patient codesrequire that all threekey components bemet or exceeded.""""""""SPEEDBAR DOCUMENTATION REQUIREMENTS FOR NEW- AND ESTABLISHED- Patient OFFICE VISITS New Patient visits require more work than estab-lished Patient visits at the same level, and this isreflected in the coding requirements as well as thereimbursement for new Patient visits.

6 A key to differentiating between new and estab-lished patients is understanding two terms used inCPT s definition of a new Patient : professional services and group practice. Medicare s definition of a new Patient is slightlydifferent than CPT s. KEY POINTSM edical Typical face-to-face HistoryExamdecision makingtime (minutes)99201 Problem-focusedProblem-focusedStraightfo rward1099202 Expanded problem-focusedExpanded problem-focusedStraightforward20 99203 DetailedDetailedLow3099204 ComprehensiveComprehensiveModerate459920 5 ComprehensiveComprehensiveHigh60 All three key components must be Typical face-to-face HistoryExamdecision makingtime (minutes)99211 Not requiredNot requiredNot required599212 Problem-focusedProblem-focusedStraightfo rward1099213 Expanded problem-focusedExpanded problem-focusedLow1599214 DetailedDetailedModerate2599215 ComprehensiveComprehensiveHigh40 Two of the three key components must be PatientEstablished PatientSeptember 2003!w w w.

7 A a f p . org/f pm!F A MI L Y P R A C T I C E MA N A G E ME N T!3 5new Patient code since there was no face-to-face encounter during the inpatient stay. Consider the Patient who is new to thecommunity and needs a refill of her oral con-traceptives. You agree to call in a prescriptionthat will meet her needs until she can be seenin your office the following week. When yousee her for her well-woman visit, you report anew Patient preventive medicine service codesince you did not have a face-to-faceencounter with the Patient when calling in herprescription. If you are in solopractice, all you needto remember to differ-entiate new patientsfrom established onesis whether you pro-vided a face-to-faceservice within the lastthree years. The situation is different, however,for group group practice Although groups with multiple practice sitesmay operate independently, with each caringfor its own Patient population and maintain-ing its own medical records, they are consid-ered a single group if they have the same taxidentification number.

8 In a single-specialty practice, the Patient sencounter should be reported with a code ina new Patient category only if no physicianor other provider who reports services usingCPT codes in that group has seen the patientwithin the last three years. For example, let ssay your partner saw a Patient who is new toyour practice in the emergency department(ED) over the weekend. The following weekyou see the Patient in the office. Since some-one else in your practice has seen the patientwithin the last three years, you have to use anestablished Patient code. This is the case eventhough the Patient had not been seen in theoffice and there was not an established medical record there. In a multispecialty practice, a patientmight be considered new even if he or she hasreceived care from several other physicians inthe group and a medical record is distinguishing factor here is the specialtydesignation of the provider. For example, takea Patient who has been seen regularly by thepediatrician in your group.

9 The Patient isnow 18 years old and wants to transfer care toa family physician inthe same she sees thefamily physician,she ll qualify as anew Patient becausethe family physicianis in a different spe-cialty than her previ-ous physician. This is the case even thoughthe family physician might be treating her foran existing problem and referring to herestablished medical record. Medicare has a list of specialty and sub-specialty designations it recognizes for pay-ment purposes. Other payers may use thissame list or may recognize more areas ofexpertise based on credentialing you change practices Consider this scenario: Suppose you leave thepractice where you have been working for anumber of years to join a new group in anearby community. Some of your patientstransfer their care to the new practice and seeyou within three years of their last visits. Youwould report these encounters using an estab-lished Patient code because, although you arepracticing in a new group, you have providedprofessional services to the Patient during thelast three years.

10 Note that whether the patienthas transferred his or her medical records toyour office and how long you may have hadCPT defines profession-al services as thoseface-to-face servicesrendered by a physicianand reported by a spe-cific CPT code. Multi-site practices are considered a singlegroup practice if eachsite uses the same taxidentification a multispecialtypractice, the specialtyof the provider isessential to determin-ing whether a patientcan be considered you change practicesand the Patient trans-fers his or her care toyou, the time that spassed since your lastencounter is the deter-mining factor.""""""""SPEEDBAR N E W P A T I E N T C O D E SCPT defines professional servicesas those face-to-face servicesrendered by a physician andreported by a specific CPT code(s). New patients Established patients (99201-99205)(99211-99215)Level : Medicare resource-based relative value scale (RBRVS).OFFICE VISIT RVUsNew patientsEstablished patients (99383-99387)(99393-99397)5-11 years years years years + years : Medicare resource-based relative value scale (RBRVS).