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Orthopedic Coding Alert

Reader Questions:

New Patient in Hospital Is Established in Office

Question: At a recent seminar, a provider insurance representative advised me that when our orthopedists see new patients in the hospital, we can still bill them as new patients in the office as well. But when our orthopedist treats a new patient in the hospital and then later treats him in the office, I've been billing established patient codes. Who is correct?
New York Subscriber
Answer: You are correct. CPT defines a new patient as "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."
Strategy: Show the insurance representative CPT's new and established patient definition under the heading "Definitions of Commonly Used Terms" in Evaluation and Management Services Guidelines.
The representative who spoke at your seminar may be unfamiliar with in-office coding that follows this rule, which explains why the information wasn't accurate.
A patient's status doesn't affect hospital care coding. For instance, you report initial hospital care with 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) and subsequent hospital care as 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...), regardless of whether the patient is new or established.
But if one of your orthopedists treats a patient in the hospital and later (within three years) treats the patient in the office, you must code the encounter as an established patient E/M service, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

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