Humana's Your Practice

Double-Check Coding for New,
Existing Patient Visits

Recently, Humana has learned that many practices are incorrectly coding new patient visits — members are being identified as new patients when they are actually existing patients. Humana’s coding staff has several suggestions for correctly identifying and coding patient visits.

About the problem
The relevant codes are located throughout the Evaluation and Management section (99201-99499) of the CPT® book published by the American Medical Association.

“This type of miscoding seems to occur most frequently when a health care system has multiple practices or a practice has multiple locations, and a patient is new to that office or location, but not to the system as a whole,” said Mandy Brewer, coding consultant for Humana. Other errors could be made, for example, if documentation is missing from a patient’s chart or if a previous visit was overlooked.

Correcting coding
The key elements for proper coding of new and established patients are as follows:

If a patient has been seen within the past three years by any physician under the same tax identification number (unless the physicians practice different specialties), then he or she is an established patient.
If it has been longer than three years since the previous visit, the patient is considered a new patient again, even if he or she is seeing the same physician.

In addition, the following tips can support accurate coding:

In the busy exam room, be certain to circle the appropriate level of visit on the preprinted encounter form.
Ensure that anyone who might choose the E&M code is properly educated on how to determine the correct code for the services provided.
For health care systems that include numerous physician practices, ask all patients if they have been seen at any affiliated practice.
Where possible, using a computer system that can link all practices within a large health care system helps avoid new patient miscoding for patients who see other providers within the same system.

Consequences of miscoding
Miscoding can have annoying — and costly — consequences. Some examples include:

Humana’s system will see the incorrect coding and deny a new patient visit if the member is already established with that provider. A claim line will be added that indicates the member is an existing patient. When the Explanation of Remittance is sent to the provider’s office, the conflict can cause delays while billing staff determines where to apply the payment.
Practices that apply payments electronically to patient accounts may find it frustrating to have to figure out why a payment did not seem to post correctly. It is time consuming for billers to research and determine the reason for any discrepancies that may cause bookkeeping errors.

To prevent these issues and support correct coding, Humana will audit charts more often to understand where errors occur and to help resolve these issues.