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Consult and Follow-Up; New vs. Established Patient Visits


Coding questions? We've got the answers.

Consult and follow-up

Q: If I see a non-Medicare patient admitted to observation status as a medical consult on the day of her admission, and I see her as a follow-up the next day, which turns out to be her discharge day, is my initial charge a 99213-99215 or a 99218-99220? Is my follow-up visit a 99213-99215 or a 99224-99226?

A: If I understand correctly, the patient is in observation status in the hospital both days, admitted to observation by someone else, and you are asked to consult the first day and then you followed on your own the second day.

If this is a non-Medicare patient, the consult the first day is coded 99241-99245, and the visit the next day is coded 99224-99226.

If the patient has Medicare, then day one is coded 99201-99205 or 99211-99215, depending on whether you have seen this patient before, and day two is coded 99224-99226.

New vs. Established

Q: I just read your answer to the "patients previously treated elsewhere" question in the April 2012 journal. My partners and I have a similar situation at work that makes us all very uneasy. We recently started providing services at a distinct and separate organization and location. We are not and have never been employed by this organization (we'll call it organization "B").We are employed by organization "A." We previously saw patients at organization A. We're now seeing those patients at organization B. We are instructed to bill these patients as new patients at the first visit at organization B. This makes us very uncomfortable, since we previously treated the patients. I believe that all of these patients are established with us, the physicians, even if the organization in which we are treating them is new and different. Which is the correct code, new or established?

A: The patients are established. See the definition of new and established patients on Page 4 in the 2012 Professional Edition of the CPT Manual. There is very little room for a different interpretation. It states, "An established patient is one who had received professional services from the physician..."

The changed tax ID number might allow you to avoid a payer's edits for tax ID and NPI, so it may be unlikely that anyone will notice, but it's hard to get around that definition.

E&M codes and non-ED physicians

Q: Can our PCPs bill the emergency room E&M codes when they are called in to treat their patients? Or, are those codes specific to the employed ED physicians? I have heard you can do either.

A: The ED providers get preferential treatment in the use of 99281–99285, per the AMA's Principles of CPT. If an ED physician sees the patient, that physician gets those ED codes. If a non-ED physician sees the patient and provides treatment, and the patient is not seen in the ED by an ED physician, the PCP can use the 99281-99285 series. If the patient is admitted, use the admit codes, of course.

And, if an ED physician assesses and treats a patient in the ED and uses the 99281-99285 series, then the PCP assesses and treats the patient, the PCP can also use the 99201-99215 series. These codes aren't just for the office or hospital clinic, they are for "other ambulatory settings as well."

Measuring lesion removals

Q: Do we measure lesion removals the same way we measure suture repairs?

A: No. Benign or malignant lesion removals by excision should be reported according to the excised diameter of the lesion, including the margin around the lesion considered necessary for complete excision. See the CPT manual. It gives pretty explicit instructions in the integumentary system section for all types of lesion removals.

For suture repairs, a linear measurement should be used. In some cases, you need to add the length of repairs in the same type of repair (simple or intermediate) and in the same anatomic grouping. The CPT has very clear directions here.

The short answer is that lesion measurement is diameter; suture measurement is total length of repairs. Good luck.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the September 2012 issue of Physicians Practice.

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