tci Medicare Compliance & Reimbursement - 2012 Issue 7
Reader Question: Here's When To Treat Established Patients As New
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Article Overview
This premium Q&A article is about patient status determination in medical coding and E/M administration. It helps coders, billers, and practice staff understand when a returning patient is treated as established versus new under AMA CPT guidance and how CMS policy may differ. The discussion focuses on physician specialty, subspecialty, group practice relationships, taxonomy considerations, and the impact of multiple locations or multi-specialty practices.
Why This Topic Matters
Correctly identifying new versus established patient status affects E/M coding compliance and can prevent billing errors when a patient returns to a practice for a different complaint or sees a different physician. The article is especially relevant for group practices and otolaryngology settings where specialty and subspecialty distinctions may change how encounters are classified.
Article Sections
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Question
Introduces a patient-status scenario involving a return visit to a practice and asks how the encounter should be classified for billing purposes.
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Answer
Summarizes the general approach to determining patient status under the applicable professional service and group practice framework.
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Caveat
Notes a group practice condition that affects how the status rules are applied across physicians billing under the same group number.
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Change in 2012
Discusses the 2012 CPT narrative update and compares it with CMS interpretation in the context of specialty and subspecialty distinctions.
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Distinction
Explains how the analysis may differ in a multi-specialty practice when a patient sees physicians of different specialties within the group.
What You Will Learn
- How returning patient status is evaluated in the context of professional services and group practices.
- Why AMA CPT guidance and CMS policy may not always align on new versus established patient definitions.
- How specialty, subspecialty, taxonomy, and practice structure can affect patient classification.
- How multiple office locations and multi-specialty arrangements relate to patient-status determinations.
Who Should Read This
- Medical coders
- Billing staff
- Otolaryngology practices
- Practice managers
- Compliance professionals
- E/M coding reviewers
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