Determining the difference between New/Initial and
Established E+M Codes
We have found that many physicians run into some confusion when coding and billing for evaluation and management (E+M) services, regarding when to code new/initial or established visits. The term “new” is used for office visits and “initial” for hospital care. Codes are based on if you see the patient in the office or in a hospital/nursing home.
In the office:
A new patient is one who HAS NOT received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.
Subsequent visits will be coded as established, if the patient is back in the office within three years of a new visit.
Initial hospital encounter is the first time you see a patient during that admission regardless of if/when you have seen them previously. It does not matter if you have seen them before in your office.
Additional visits during that stay will be coded as subsequent.
Below are some examples:
You saw a patient once in the office for an ingrown toenail. They came back 2 years later for plantar fasciitis. This would be an established office visit.
You billed an E+M code after seeing a patient in the office. You then admit them to the hospital on your service. Once you see them in the hospital, you would then bill an initial E+M hospital visit.
You follow a patient in the hospital who you have never seen before. They get discharged and come to see you in your office, where they have never been, a week later. This would be an established office visit, because you know this patient. You have seen them somewhere in the last three years.
A patient you were taking care of in the hospital get discharged but re-admitted 3 days later. When you see them in the hospital this is an initial E+M hospital visit, because it is the first time you are seeing them for that admission.
What is a consultation code and when do you use it? Please be aware that consultation codes are not defined as a patient being sent from another doctor to you for your opinion. A consultation code can be used when a patient is referred to you, you provide your opinion or advise, and then send them back to the doctor who referred them to you. In order to code a consultation, the patient must be sent back to the referring doctor. This occurs less often for podiatrists, as the podiatrist often keeps the patients who was sent over for foot issue. In the case where a patient comes to your office for a second opinion on a surgery, and after examining the patient you agree the patient needs the surgery, you then send that patient back to his physician for that procedure. This would be coded as a consultation.
It is extremely important to note, never use a consultation code for Medicare patients. They do not exist for Medicare.
I hope this helps clarify how to determine the correct codes to use in certain circumstances you may encounter. For more help with coding and billing, please contact us at Vital Profits where we have certified coders and billers on staff. We will be more than happy to help you.
Wishing you all a very Happy Holiday season from the team at Vital Profits.
Joy and Peace in 2019!