Outpatient Billing and Coding
Authors: John Malaty, Lisa Gilbert, Elizabeth Close, Wendy Shen, Karl Clebak, Paul Cleland, Benjamin Silverberg, David Voran, Nadine Nixon, Samuel Le Church
There are many types of outpatient visits and, thus, different codes assigned to each. After differentiating the criteria for new patients versus established patients, and Medical Decision-Making, we will cover coding in the following situations in the tabs below.
New and Established Patients
In the outpatient setting, it is important to distinguish “New” patients from “Established" patients for many types of visits. In general, New patient visits have higher reimbursement than Established patients to make up for the extra time and energy spent with intake and documentation.
A New patient is one who has not received professional services from you or from your colleagues within the same specialty, within the same medical group, within the last three years.
• If the patient has seen you or a family medicine colleague in your medical group during the last three years, that patient is considered Established.
• If the patient has seen a different type of physician (or a sub-specialist in family medicine, such as sports medicine) in your same medical group, the patient is not considered Established for general family medicine.
• If the patient was seen by you or your colleagues only in the hospital, that patient is also not Established as an outpatient visit. Telehealth follows the same rules, but in some states, you may not be able to see a New patient with Telehealth.
Generally, this is straightforward, but it can be confusing in large medical groups that share an Electronic Health Record (EHR). Let’s practice some of the challenging situations.
Example 1: For years, a 17-year-old patient has seen a Pediatrician who is part of a large multi-specialty group. He is then seen the following year for a well adult visit by a Family Physician in the same office.
→Answer: New patient
Reason: Although in the same group, a physician with a different specialty saw the patient.
Example 2: A patient sees a Family Physician at one office location and, two years later, sees another Family Physician at another physical location, but within the same medical practice (same tax-payer EIN).
→Answer: Established patient
Reason: Despite the different locations, the family physicians are part of the same medical group.
Example 3: A patient sees a Family Physician for regular care, and then sees another Family Physician with subspecialty in Sports Medicine within the same office.
→Answer: New patient to the Sports Medicine Family Physician
Reason: Although both are family physicians in the same practice, one has a sub-speciality and is seeing the patient for sub-speciality reasons. This is true as long as the Sports Medicine physician is considered a sub-specialist at the practice and does not also practice Family Medicine within the same tax-payer EIN. In that case, check with the office manager.
Example 4: An OB patient delivers with her Family Physician who then cares for both mom and newborn in the hospital. The newborn is brought to the office for a well-child visit a week later. The office has a different EIN Tax number than the hospital but has the same EHR system.
→Answer: New patient
Reason: The newborn hasn't been seen in the office yet and even though the family physician saw the newborn in the hospital, the office is a different medical practice.
Example 5: A patient was seen by your colleague in the clinic 1 year ago. You perform a video Telehealth visit with the patient.
→Answer: Established patient
Reason: The patient has already been established in the clinic.
Pro-tip: If you are employed, find out which family physicians and locations are in your same medical group (based on EIN tax ID). Remember, just because you are part of a large organization doesn’t mean you are automatically part of the same medical group as every other employed family physician. Conversely, different physical locations can be part of the same group.
Not all types of codes differentiate New from Established patients, but most do. After you determine New vs Established, assign each visit an “Evaluation and Management” (E/M) CPT code. Remember that E/M codes include a wide range of services provided by a physician (or other qualified healthcare professional) and range from 99202 to 99499. We will address the most common codes you will use as a Family Physician.