New patient or established?
The definition makes a difference
By Ted A. Arkfeld
Understanding the difference between a new patient and an established patient should be easy: A new patient is one you have never seen before; an established patient is one who has previously used your services.
But are you sure? Consider this scenario: An existing patient who has been receiving care and having the services billed to his group health insurance is involved in either an auto accident or an on-the-job injury.
When you bill for your exam of this patient, should you:
(a.) Bill the auto or workers’ comp insurance company for a new-patient examination; or
(b.) Bill the auto or workers’ comp insurance company for an established-patient examination?
The correct answer is (b).
Unfortunately, many offices are billing this as a new-patient exam using one of the common new-patient CPT codes, such as 99202, 99203, or 99204.
Why the error? Blame hand-me down training — training passed on from one person to another. The trainer erroneously learned (and subsequently has taught to others) that when a new injury arises from either an auto injury or an on-the-job accident, the exam should be billed as a new-patient exam, even though the patient was currently under care.
The current-procedure terminology (CPT) codebook from the American Medical Association (AMA) is very explicit in its definitions of new and established patients. And it makes no mention of injury in the use of the evaluation and management (E/M) code:
• New patient. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.
• Established patient. An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice within the past three years.
Any patient who has received professional services in your office either by you or another chiropractor in your group setting is considered an established patient.
Incorrectly coding and billing an insurance carrier can be an expensive mistake. It can result in a post-payment audit that can cause the practice to pay back large amounts of monies to the insurance carrier.
Avoid this and similar mistakes. Make sure your staff is well trained in coding and documentation, and make sure that training is not of the hand-me down variety.
Ted A. Arkfeld, DC, MS, CICE, CPC, is the president of Advanced Compliance Technologies PLLC — a consulting firm specializing in billing, coding, and compliant documentation. He can be reached at 989-614-0261, firstname.lastname@example.org, or through www.arkfeldcompliance.com.