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Office visit Vs inpateint

SuperCoder Answered Mon 30th of November, 2009 10:45:45 AM

A patient comes into the office for a follow-up appointment after being released from an inpatient hospitalization. The patient has never been to your office before. What is the appropriate code for the office visit ?

SuperCoder Answered Mon 30th of November, 2009 11:28:39 AM

Correct answering to the query with this much information is a bit tricky. As per the scenario, the patient comes for a “follow-up appointment” to a physician’s office to whom the patient has never been before, after being released from an inpatient hospitalization. Two probable situations may take place here: 1) the physician belongs to the same group practice or same specialty with whom the patient was treated in the recent inpatient hospitalization (within last 3 years / 36 months); or 2) the physician does not belong to the same specialty or group practice.

Now if the physician belongs to the same specialty or group practice (chances are more in this case, because a patient is usually referred to a physician who is “in-network” with the hospital or who belongs to same group practice / specialty, for follow-up visit after release from an inpatient stay) the patient becomes an “Established patient”. When a patient is “established”, the CPT code for the follow up visit should be in the category 99212 – 99215 (Office visit – established patient) (the exact E/M code requires to be chosen based on the documentation where at least 2 of the following 3 key components must be present with proper level – history, examination and medical decision making).

On the other hand, if the physician does not belong to the same group or practice and if the patient never came in contact even with a physician of same group practice or specialty during last inpatient stay or in past 3 years, the patient becomes a “new patient”. In case a patient is new, the CPT code for the follow up visit should be in the category 99201 - 99205 (Office visit – new patient) (the choice of exact E/M code depends upon the documentation of at least 2 of the following 3 key components at their proper level – history, examination, medical decision making).

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