New or Existing Patient Coding

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March 31, 2016

Question:
If I see a new patient (9920x) for an ear problem, then they come back to see me for chronic sinusitis a year later, can I bill as a new patient visit (9920x) the second time or is it an established patient (9921x)?

Answer:
No, this would be an established patient (99211-99215). If you or another otolaryngologist in the same group practice treat the patient in the past three years (face-to-face), the patient visit would be coded as an established patient even if you are evaluating a new problem. By CPT definition, “a new patient is one who has not received any face-to-face professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” An established patient is one who has received professional services (face-to-face) from the physician or another physician in the same group and the same specialty within the prior three years. Unfortunately, payers do not recognize the different subspecialties of otolaryngology.

*This response is based on the best information available as of 03/31/16.

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