General Surgery Coding Alert - 2019 Issue 1
Guidelines: Go Beyond the 3-Year Rule to Assign Patient Status Accurately
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Article Overview
This article is a coding guidance piece for CPT evaluation and management reporting that focuses on determining whether a patient should be considered new or established. It reviews the broader criteria tied to prior services, service type, specialty considerations, and common edge cases that can affect status assignment. The discussion is aimed at coders, billers, and clinical office staff who need to apply patient-status rules accurately and avoid documentation or payer issues.
Why This Topic Matters
Correctly identifying patient status affects E/M reporting, reimbursement, and compliance. The article helps readers understand why seemingly routine prior encounters may not establish a patient and why status errors can create billing and audit risk.
Article Sections
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There’s More to the 3-Year Rule Than Meets the Eye
Introduces the broader CPT framework for determining patient status and explains that multiple criteria may affect whether a patient is considered new or established.
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What Are the Exceptions to This Rule?
Discusses common situations that can create exceptions or misunderstandings in patient-status assignment, including encounters that do not involve full professional evaluation and management services.
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Can We Use 99211 for a New Patient?
Addresses a frequently asked question about a common office visit code and its relationship to patient status and established-patient reporting.
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So, Why Does This Matter?
Explains the reimbursement and compliance importance of assigning patient status correctly and highlights the documentation implications for different visit categories.
What You Will Learn
- How CPT patient-status concepts extend beyond a simple time-based rule
- Which general factors can affect whether a patient is new or established
- Why certain prior encounters may not count toward established status
- Why patient-status errors can create billing and compliance risks
- How patient status relates to documentation expectations for office visits
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Physician practice managers
- Clinical office staff
Codes Discussed
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