New or returning patient? Understanding the coding nuances

Q: If we have a patient who is being seen by a physician for a problem that was already treated by another physician in the group, is the problem considered a “new” problem to the second provider?

A: This is one of those questions that is not consistently defined in the main body of CMS and CPT  documentation guidelines. We have clear guidance on what a new patient is, but not always what a new problem is. 

As you are likely aware, the “new problem to the examiner” is an element of the decision-making tables that carries some significant weight when qualifying for a low versus moderate (usually level 3 vs. level 4) level of decision-making.

So in terms of the federal tables, it would appear that “to examiner” would indicate that regardless of whether another provider in the group had seen the patient, or the problem, that the problem is a “new problem to the examiner.”

Use of the term “examiner” instead of “provider” in the tables may even be designed specifically to address the issue of the “new problem.” Had the word “provider” been used, it would have opened the door to the “interchangeable parts” approach when seeing different providers in the same office-back to the new vs. established patient question. 

But while there would seem to be some case for regarding the second provider’s assessment of the same problem as an established problem-given the likelihood of a common electronic health record (EHR) with a description of the problem at an earlier encounter along with treatment, etc.- that is not the letter of the law.

One Medicare Administrative Contractor (MAC) has stated for purposes of the medical decision making for the E/M service, the “problem” is a new problem to both physicians. In both instances, the physician has not addressed the problem previously. The second physician would submit an appropriate level of established patient service since a physician in the same group with the same specialty provided a face-to-face service within the previous three years. While the problem is new to the second physician, the patient is not.

All payers may not have this policy, but there is clear precedent for it.

Q:

If the patient comes to a physician not because of a problem but just to establish care with a new PCP what is acceptable as a chief complaint? Can the office just use “new PCP”? Or “here to establish care?”  That doesn’t seem like a chief complaint but there really isn’t any other reason. Any advice?

A: It really doesn’t matter what the chief complaint (CC) is--the only requirement from the documentation guidelines is that there be one, and that it is as specific as possible. 

If it’s “to establish care” so be it. The bigger issue is, what are you going to use as a diagnosis code? If it’s a preventive visit the CC and HPI should say that. If it’s problem-oriented obviously the CC and HPI should be about that. 

There is no CPT code for a “get established” visit. And if you show it like it really is to an insurer, you can be pretty certain that tit won’t be covered. So what most providers do is fudge it. They’ll do a wandering HPI with some past medical history, maybe talk about some concerns. What does the physician call it? Providers will say, “I can always find something.” But the bottom line is it should be either preventive, or a problem-and it should say so in documentation.

Q:

I have a transitional care management (TCM) question. The patient is seen by the primary care physician eight days after hospitalization. There was a phone call within two days of discharge. The TCM code was billed. The patient returns a week later with continued issues related to the problem he was hospitalized for. Can that second visit be billed?

A: Absolutely, as a regular E/M visit, a 99213- or 99214- type code. The TCM only includes the first visit following the hospitalization. Others can be billed in the same 30-day period and are separately payable.

Q:

For an established patient, does the decision making have to be one of the “two out of three” components used to choose the evaluation and management code? The CPT book doesn’t say that.

A: Many practices adopt this policy to be certain that all notes are anchored in medical necessity, not just a lot of EHR history and exam.

One Medicare contractor has said, “if not using the MDM, how are you showing medical necessity for the service?” That MAC went on to say “If you can answer that question through your medical record documentation by using the other two components; history and exam, then the medical decision making would not be required.”

The use of decision-making as a required element is a measure of prudence and responsible coding.