I respectfully disagree with the coding advice in “New patients for a new physician?” [Coding & Documentation, April 2007]. Current Procedural Terminology (CPT) does not differentiate between locations of service when defining a new patient. It does, however, define a new patient as “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.”
When the physician sees a patient in his new practice after having left his residency practice, the patient would clearly be defined as new. In fact, the first visit would be billed under a new tax identification number. This fulfills the requirement of belonging to a different group practice.
In this and the second example in the article, the practices have the added burdens associated with new patient visits: medical and insurance information must be collected and verified, a chart or new record must be made, confidentiality paperwork must be given to the patient and filed, and so on. In each case, the patient qualifies as new.
Dr. Samlowski is interpreting the CPT definition incorrectly. The determining factor is whether the physician has seen the patient in the past three years or another physician of the same specialty who belongs to the same group practice has seen the patient in the past three years. Dr. Samlowski's interpretation of the definition is that the patient is new if he or she hasn't been seen by “the physician ….. who belongs to the same group practice” or “another physician of the same specialty who belongs to the same group practice.” Therefore, he concludes that because the physician changed practices he can bill a new patient visit code when seeing a patient he saw in his previous setting.
Per CPT, if a physician or any physician of the same specialty in the same group practice or any physician for whom a physician is providing call coverage has provided a face-to-face professional service in the past three years, the patient is established. It is the relationship that is the determining factor.
If you follow the flow chart in the CPT Evaluation and Management Services Guidelines, the first question asks whether the patient has “received any professional service from a particular physician, within the past three years, who is now reporting service?” If the answer to this question is “yes,” the patient is established.