Wrong Answer Could Weigh Heavily on your Medical Coding Practice

In Medical Coding a mistake can also impact on your practice’s reimbursements.

Your ophthalmologist provides a new patient with a standard office-visit E/M. You use an established patient E/M to report the encounter. And if you thought it’s no big deal, you are wrong.

Not only is the coding wrong, this mistake will also have an impact on your practice’s reimbursements. To add to it, Medicare’s non-payment of consultation codes means that medical coders will have to answer the new versus established question more often than before.

For Medicare and payers that follow their lead, medical coders will now have to choose the correct code, new or established, to bill for what used to be consults and didn’t have a new versus established component concept.

Here’s an expert advice on new and established patients.

If you ignore new patient E/Ms, you could be losing your deserved money

For physician practices, the difference between new and established patient codes is the payment rate. Think about this comparison of average national payouts for new and established level-two E/m codes respectively:

99202 pays about $68 per encounter (1.86 transitioned nonfacility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.8729)

99212 pays about $40 per encounter (1.08 transitioned nonfacility RVUs multiplied by the temporary 2010 Medicare conversion rate of 36.8729).

That is almost $30 lost if you report 99212 instead of 99202 mistakenly. The main difference between a new and established patient visit, service-wise, can be minimal: Often it includes simple tasks like setting up a new chart and quizzing the patient a little closer to get familiar with him.
First ask 3-year question

If your patient has had a face-to-face service with the ophthalmologist within the last three years, then the patient is considered established. So let us say a patient reports to your ophthalmologist and gets a level-three E/M service on April 20, 2010. The patient’s record points to the fact that she received a previous face-to-face E/M service from another ophthalmologist within the group on Dec. 14, 2008. Since this is an established patient, you should report 99213.

For established patients, Face Time is a must

As a coder, what would you do when the patient has received treatment from your ophthalmologist within the last three years, however the doctor didn’t actually lay eyes on the patient? This is a different coding situation; here’s what you need to do: ‘Interpret the phrase ‘new patient’ to mean a patient who hasn’t received any personal services – to put it separately, an E/M service or other face-to-face service from the physician or physician group practice within the last three years.

This means that you might be able to report a patient as new if your ophthalmologist provided services for the patient less than three years ago, provided it wasn’t a face-to-face service.

Check specialty when deciding status

Coders who work in multispecialty practices will have to pay attention to one more new/established patient status rule.

For more on this, and other evaluation & management coding guidelines, stay tuned to a medical coding guide like Supercoder