Health Information Management

Assign proper E/M levels for new versus established patients

APCs Insider, August 24, 2007

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QUESTION: I work in an urgent-care setting. How do I distinguish between new and established patients when assigning E/M codes?

ANSWER: The question of how to distinguish new versus established patients in the clinic comes up often and for good reason; it can be quite confusing. The answer to your question lies in 2007 OPPS final rule that was published in the November 24, 2006 Federal Register. On p. 170 of the Federal Register(www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms1506fc.pdf), CMS offers guidelines to differentiate between new and established patients in the clinic setting.

However, because hospitals will continue to report CPT codes for calendar year (CY) 2007, they must continue to distinguish between new and established patients, according to the CPT code descriptor.

Therefore, these codes will continue to be payable under the OPPS for CY 2007. The American Medical Association 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." However, the final rule states that the meanings of "new" and "established" pertain to whether a patient already has a hospital medical record number.

The original CMS guidance from the April 2000 OPPS rule was if a patient has a hospital medical record (regardless of when it was created), that patient is an established patient according to the final rule. Therefore, the same patient can be "new" to the physician but an "established" patient to the hospital. The opposite could be true if a physician has a long relationship with a patient but has no medical record at the hospital. In last year's rule, CMS added a 3 year condition which begs the question if CMS means that a patient can be "new" if there has not been an encounter/entry to the medical record at the hospital in the last 3 years.

In this case, the patient would be "established" with respect to the physician and "new" with respect to the hospital. However, it may be unnecessary for hospitals to report consultation CPT codes if either the new or established patient visit code accurately describes the service(s) provided.

In summary, for CY 2007, providers should continue to use CPT codes to bill for clinic visits. The CPT codes for new and established visits and consultations will continue to be payable under the OPPS.

There is a noteworthy discussion in the recently released 2008 OPPS proposed rule that would migrate toward distinguishing between patient clinic visits based on new versus established classifications rather than assigning consultation codes to an APC. CMS would continue to follow its initial definition of a new patient-one who does not have an established medical record number-and an established patient-one who already has an established medical record number.

In order to adhere to CMS' guidance on established versus new patients, be sure to educate the staff members who are responsible for assigning the charges for patient visits. They need to know the requirements for billing an established patient clinic E/M code versus a new patient clinic E/M code.

(The above Q/A was previously published in the September 2007 APC Answer Letter).



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