3 Steps For Accurate Billing Evaluation and Management Services in Your Practice

3 Steps For Accurate Billing Evaluation and Management Services in your Practice

Begin by asking questions when determining the accuracy when billing for evaluation and management.

Accurate Billing Evaluation and Management

Step# 1 – Is the patient seen face-to-face in the last 3 years?

The 3-year rule describes that an established patient is someone who was seen by the same physician (or any physician) under a group and of the same specialty or sub-specialty.

One good example is: A patient with a chronic back pain comes in to your office. Dr. John who is a part of the group, a Physiatrist saw the patient. The history shows that the same patient was seen by Dr. Smith 30 months ago for the same problem and both physicians are under the same group and with the same specialty. This patient is considered as “Established Patient” following the 3 year rule for Evaluation and Management.

Step# 2 Determine if the Patient is New or Established when billing for evaluation and management

So when billing for evaluation and management, just remember that a “new patient” is defined as an individual who has not received any professional
services from the physician/non-physician practitioner (NPP) or another physician of the
same specialty who belongs to the same group practice within the previous three years.

An established patient is an individual who has received professional services from
the physician/NPP or another physician of the same specialty who belongs to the same
group practice within the previous three years.

So by reading the above, it is very easy to determine what type of patient are you going to be billing for – New or Established patient.

You also must be aware that it is possible you have different sub-specialty in your practice.

For Example: A Family Practice physician is the primary care doctor for an established patient comes in to the office with a sports injury. The patient was then seen by a Family Practice physician whose “Sub-specialty” is Sports Medicine . This patient becomes a “New Patient” due to the fact that the patient was seen by one of its physicians who has a different sub-specialty from the other physician (under the same group).

Choosing the right patient type (either New or Established) require a “Face-to-Face Encounter”. Some physicians may experience providing a non face-to-face encounter like going over the diagnostic reports over the phone – this does not automatically establish a “New Patient” type since there is no face-to-face encounter had occured.

On the Medicare Claims Processing Manual – section 30.6.7, it says there – “An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

Now with the Consult Codes – 99241-99245. These service requires a “request” for the physician to evaluate the patient and sends back the reports to the requesting health care provider. There is no “New” or “Established” patient in this case, regardless of the patient’s status. So if you are billing for Consultation, choose from your consult codes 99241-99245.

Step #3  Choose the level of your Evaluation and Management based on documented components within the E/M encounter based on History, Physical Exam and Medical Decision-Making.

The AMA on CPT® in 2006 had added the text to clarify that all of the key components (History, Physical Exam and Medical Decision Making) must meet or exceed the stated requirements to qualify for a particular level of service for office, new patient (99201-99205), hospital observation services (99218-99220), initial hospital care (99221-99223), office consultations (99241-99245), initial inpatient consultations (99251-99255).

Additionally, per Per CPT®, you must meet or exceed the stated requirements for two of the three key components for established patient office visits (99212-99215), subsequent hospital care (99231-99233), subsequent nursing facility care (99307-99310) and others.

You may also report your evaluation and management service “based on time” if the physician spent more than 50% of the visit on counseling and coordination of care.

If I may add this – don’t let your different practice location confuse you. Regardless where the patient was seen, the patient will remain an established patient based on the above explanation. You may see the patient from the other location due to convenience for the patient (say its near her/his office), this will not change the patient being an “established patient”.


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Medical Billing and Coding Blog Pinky Maniri

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Author: Pinky Maniri

Ms. Pinky, as she is fondly called - is a Reputable Professional Consultant and Expert in Practice Administration, Medical Billing, Coding, Health Information Technology, Insurance Credentialing and Compliance for Physician Offices. Well-educated with a Degree in Computer Systems Engineering and a background in Clinical Nursing and Small Business Management. Her professional mission is to make sure her clients/physicians maximize reimbursement while they remain compliant with the current rules, changes, guidelines and policies. Read More About Ms. Pinky here and See what Other's say about her Expertise Testimonials

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