August 22, 2019

Question:
One of our pain management doctors saw a patient in the hospital at the request of the orthopedic surgeon. The patient was discharged and is coming to our office for the first time to see the same physician. Can we bill a new patient visit?

Answer:
You cannot bill a new patient visit because the physician saw the patient face-to face in the hospital. Per CPT guidelines for a new patient; “A patient who has not received professional services from the physician/qualified healthcare professional or another physician/ qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.” Since the pain physician provide a professional service to the patient an established patient visit must be reported with CPT codes 99212-99215 depending on documentation and medical necessity.

*This response is based on the best information available as of 08/22/19.