Evaluation and Management Coding (E/M); New Patients and Modifiers

When you talk about coding and billing, “New” isn’t always “New.”

The terms “New” and “Established” come into play when dealing with Evaluation and Management (E/M) codes. Simply put, these codes pay you to think, and they take into account the amount of time it will take to gather information and make up your mind. The variable between cases, which determines how much you earn, is often how much you need to learn about your patient. New patients require longer interviews and more testing than those established patients who are familiar to the practitioner. As a result, the codes that require the most consideration typically have greater Relative Value Units (RVUs).

By contrast, the four Chiropractic Manipulative Treatment (CMT) codes already have the time factored in that is required to make evaluations. These are 98940, 98941, and 98942 for the spine, and 989143 for extra-spinal regions, such as extremities. (See the Sidebar: “It’s About Time.”)

When is a Patient “New?”

Under what conditions is a patient considered “new”? The Centers for Medicare and Medicaid (CMS), and the American Medical Association, publishers of the Current Procedural Terminology (CPT©), use a “three-year rule.” If you have not seen the patient for three years, then in most cases you can consider a visit to be an “initial” visit and claim the professional services time you spend becoming familiar with the case.

If a patient has been seen within three years, then that patient is “established”. Only it is often not that simple.

When is a Patient “Established”?

According to the Evaluation and Management Services Guidelines for New and Established Patients in CPT 2012, if one doctor is covering for another, that is, if he or she is “on call,” and if a patient presents whom requires E/M services, the encounter is to be classified as if it would have been by the physician who is not available, even though the patient may be “new” to the covering practitioner.

Of course, sometimes patients switch doctors. In this case the choice of being new or established depends upon the legal and business relationship between the two practitioners:

  • A new patient would be one who has not received any • professional services from a physician or another physician of the exact same specialty, who belongs to the same group practice, within the past three years.
  • An established patient is one who has received profes• sional services from a physician or another physician of the exact same specialty, who belongs to the same group practice, within the past three years.

As multi-disciplinary practices become more common, this nuance of this rule may increase in importance. For instance, what would happen if a Chiropractor inherits some patients from a Doctor of Osteopathy, who must take a leave of absence for some reason?

Note: No distinction is made between new and established patients when a patient presents in an emergency department.

For further information about E/M services, see your 2012 ChiroCode Deskbook, pages F-16 to F-26.

Figuring the Fees

Not only do equivalent E/M codes pay less for established patients than new ones, but there is a trick to the way codes are figured which tips the scales. Recall that an E/M code includes three subcomponents:

  • History (time spent varies with depth of inquiry)
  • Examination (the more tests, the more extensive the exam)
  • Difficulty of Clinical Decision Making (the more ef• fort is consumed, the more complex the case is presumed to be.)

These three can be abbreviated as H-E-C.

The CPT E/M codes vary in value according to the following:

  • First is the category, that is, the location where the service is performed (outpatient vs. inpatient).
  • Second is whether the patient is new or established.
  • Third is complexity of clinical decision making. The CPT codes in each category range from basic to complicated, depending on the difference in the intensity or difficulty of each of the H-E-C subcomponents.

The most complicated cases are assigned the highest RVUs, hence they earn you more. But there is a trick to establishing which code to use within the category:

  • For new patients, all three of the components must meet or exceed the E/M code selected.
  • For established patients, two of the three CPT com• ponents must meet or exceed the E/M code selected.

This sounds confusing, but it is easy to grasp:

Consider the case of a new patient, using the table shown in Figure 1 on page 5. The three components all meet or exceed the E/M code chosen. In this case, 99202.

Now consider the case of an established patient, using the table shown in Figure 2 on page 5. Only two of the three components must meet or exceed the E/M code chosen. In this case. 99213.

Using Modifiers -25 and -22

Modifiers provide a way for the practitioner to report or indicate that a procedure or service has been performed but has been altered by some specific circumstance; however, the procedure or service was not changed in its definition or code. See Section H-Procedures in the Behavioral Health MultiBook for further guidance on modifiers.

Modifier -25 is used for an established patient when tthe patient's condition requires a significant and separately identifiable E/M service beyond the usual care associated with the procedure that was performed.

If this occurs, the reasons for the extended decision must be carefully documented. The -25 modifier indicates that a significant, separately identifiable evaluation and management service was provided by the same healthcare provider on the same day as the original service. List the main code in the first line. List the E/M code (with an attached -25 modifier) in the box below, and put the modifier in the box to the right of the E/M code.

This can only work if the E/M code:

  • Exceeds the usual preservice or postservice work as sociated with the CMT code
  • Meets the level of service required by the E/M code used, and is
  • Supported by appropriate documentation.

This last point is important. You must document this extra service. Attach your E/M counseling record to the submitted claim form (CMS-1500, or other), or as part of the Electronic Medical Record. Give an explanation in Box 19 for the significant, separately identifiable E/M service that indicates the length of time spent, or that points to the attached counseling report, or do both.

The increased service modifier, -22, is for prolonged service which is greater than the highest time recognized within the appropriate E/M category. When using modifier -22, you must document the circumstances within Box 19 on the paper or electronic CMS 1500 form, or attach a report and point to it in Box 19. (There is room for four modifiers per code on the CMS-1500. Insert modifier -22 in the second box, to the right of modifier -25.)