Reporting New And Established E/M Codes

Hospital outpatient departments must determine whether a patient is ?New?or ?Established? when billing Evaluation and Management (E/M) services. For hospital-based clinic visits, the facility fee (837i or UB04) and the professional fee (837p or CMS1500) require separate determinations. Different rules apply to code assignment for professional fees and facility fees; it is common and correct to assign different E/M codes to each claim for the same visit.

E/M coding for professional fee billing is discussed in the CPT® Guidelines, available on a link next to the CPT® Codes report on the PARA Data Editor Calculator tab:

New versus Est ablished Pat ient Coding:

E/M visit codes are selected according to a number of factors, including whether the patient is new or established from the perspective of the billing provider In a provider-based setting, the hospital may appropriately bill a new patient code when the physician bills an established patient code and vice versa.

For facilit y fee claim s (837i or UB04):

Use the following guide in selecting new versus established patient E/M codes:

- A ?new pat ient ?means a patient who has not received any face-to-face services, i e , E/M service or surgical procedure, from the facility within the previous 3 years

- An ?est ablished pat ient ? is one who has been registered as an inpatient or outpatient of the hospital within the 3 years prior to the visit

For Professional Fee claim submission (837p or CMS1500), the following defines a new vs established patient in selecting the appropriate E/M code:

- A ?new pat ient ?means a patient who has not been seen for face-to-face professional services by the provider or a provider of the same specialty in the same group within the previous 3 years An interpretation of a diagnostic test, reading an x-ray or EKG etc , in the absence of a face-to-face service does not affect the designation of a new patient

- An ?est ablished pat ient ? is one who has been seen for face-to-face services by a provider or a provider of the same specialty in the same group within the previous 3 years If a provider leaves a group practice, and practices elsewhere, and a patient follows him or her to the new site, the patient is still considered established if seen in the last 3 years.

Provider of t he Sam e Specialt y:

CMSdefines ?same specialty?as being within the same group of taxonomy codes Medicare has assigned to a specialty code The specialty group codes were previously published in a PDFfile, but now they are available in an online database at the link below: https://data cms gov/ provider-characteristics/ medicare-providersupplier-enrollment/ medicare-provider-andsupplier-taxonomy -crosswalk

While Medicare offers significant differentiation in specialty codes assigned to physician specialties, all Nurse Practitioners are assigned to Specialty Code 50, regardless of the type of Nurse Practitioner taxonomy code. Here is an example of the data exported using the query: